LIBRARY OF CONGRESS. 






Slielf.i\.3..1J 



UNITED STATES OF AMERICA. 



A MANUAL 



OF 



NERVOUS DISEASES 



AND THEIR 



Homeopathic Treatment 



A COMPEND FOR 



STUDENTS, COLLEGES AND PHYSICIANS 



BY GEORGE F. MARTIN, M. D. 

PROFESSOR MENTAL AND NERVOUS DISEASES HAHNEMANN 
HOSPITAL COLLEGE, SAN FRANCISCO 



'S^'^- 



NEW YORK AND CHICAGO 

MEDICAL CENTURY COMPANY 

1896 



[I 



q;<^ 






Copyright, 189g. 
By medical CENTURY COMPANY. 



PREFACE. 



^^^^-|^N OFFERING this little work to the profession it is the 
* I object of the author to furnish a treatise upon ner- 
^^ vous diseases which will be concise and at the same 
time practical, both for the student and the busy practi- 
tioner. It is not intended as a substitute for the larger 
text-books on the subject, but to be merely an outline of 
the diseases described. To the student it will take the 
place of the quiz-compend, as it has been arranged accord- 
ing to the methods used in such books. To the practitioner 
it will be of use as a ready manual in which he can quickly 
determine the character of the case that he is looking up, 
while it at the same time outlines a method of treatment. 

Though the time allotted to me by the publishers in 
which to prepare my manuscript has been brief, neverthe- 
less I have endeavored to make the book as complete and 
accurate as possible. I have entirely avoided giving any 
theories in regard to the causation or treatment of the dis- 
eases under consideration, but have given merely such facts 
as are known to be thoroughly established. In the homeo- 
pathic treatment of the diseases I have mentioned only a 
few of the most prominent remedies, with their indications 



for the special disease, and have not continued the list be- 
yond the point of utility in a manual of this size. 

In the preparation of this work I have drawn freely 
from many authors, mainly Gowers, Dana, Ranney, Bart- 
lett, Hirt, Ross and Starr. For the homeopathic treatment 
I have consulted the works of Lilienthal, Hering, Farring- 
ton, Hughes and others. While thus referring to these 
authors I have yet followed my own general plan, which I 
have used during my years of teaching, both as to the arrange- 
ment and treatment of the subject. 

It gives me pleasure to acknowledge the invaluable 
services of my wife. Dr. Eleanor F. Martin, who has most 
carefully arranged and corrected my manuscript, and has 
frequently suggested points which might possibly have 
been omitted by myself. 

In conclusion I beg the indulgence of the readers to 
any errors which may be discovered, and trust that their 
criticisms may be as forbearing as the author's purpose in 
writing the book has been sincere. 
March, 1896. The Author. 



CONTENTS. 



PART 1. 

Page. 

Anatomy and Physiology of the Nervous System. , . . 1 

PART 11. 
Symptomatology 47 

PART III. 
Diseases of the Brain and Its Membranes 75 

PART IV. 
Diseases of the Cranial Nerves 135 

PART V. 
Diseases of the Spinal Cord and Its Membranes. . . .160 

PART VI. 
Diseases of Muscles 216 

PART Vll. 
Diseases of the Spinal Nerves 224 

PART Vlll. 
Functional Nervous Diseases 253 



ILLUSTRATIONS. 



Figure. Page. 

1. Chief component parts of the brain 4 

2. Sensory tract (plate opposite) 7 

3. Cortical distribution of the middle cerebral artery (plate 

opposite) . . . ; 9 

4. Convex surface of the cerebrum 11 

5. Longitudinal median section of the cerebrum 14 

6. Under surface of the brain 16 

7. Longitudinal median section of the brain 18 

8. Inner surface of optic thalamus, etc 21 

9. Relations of internal capsule of cerebrum 22 

10. General arrangement of fibres of cerebro-spinal system .... 24 

11. Diagram of cerebral cortex (plate opposite) 27 

12. Anterior view of medulla oblongata 28 

13. Important subdivisions of spinal cord 39 

14. Testing muscular strength of leg 68 

15. Testing for co-ordination 69 

16. Testing for Brach-Romberg symptom 70 

17. Testing for myoidema 71 

18. Testing for patella reflex 72 

19. Testing for ankle clonus 73 

20. Testing for ulnar reflex 74 

21. Chronic hydrocephalic heads 81 

22. Abscess of cerebellum 113 



ILLUSTRATIONS— Confzmted. 

23. Attitude in syphilitic glioma 118 

24. Same patient four years ago 118 

25. Attitude in cerebral tumor 121 

26. Handwriting in disseminated sclerosis 128 

27. Microcephalic idiot 134 

28. Infantile paralysis 178 

29. Locomotor ataxia — front view 186 

30. Locomotor ataxia — side view 187 

31. Spina bifida 213 

32. Pseudo-hypertrophic paralysis 218 

33. Method of rising in pseudo-hypertrophic paralysis 219 

34. Leprous neuritis 225 

35. Anesthetic leprosy 251 

36. Epilepsy 259 

37. Epilepsy — same patient 260 

38. Attitude in paralysis agitans 270 

39. Wry-neck 291 



A 

Manual of Nervous Diseases 



PART I. 

ANATOMY AND PHYSIOLOGY OF THE 
NERVOUS SYSTEM. 



DIVISIONS OF THE NERVOUS SYSTEH. 

WHAT ARE THE TWO GREAT DIVISIONS OF THE NERVOUS 

SYSTEM? 

The cerebro-spiual or the nervous system of animal life, 
and the sympathetic or nervous system of organic life. 



OF WHAT I>OES THE CEREItRO-SPINAt SYSTEM CONSIST? 

(1). Those parts of the central nervous system con- 
tained in the cavities of the cranium and spinal column, 
viz., the brain and the spinal cord. 

(2). The motor or efferent nerves, which convey nerve 
impulses from the centre to the muscles. 

(3). The afferent or sensory nerves, which convey sen- 
sory impressions from the periphery of the body to the 
brain and spinal cord. 

WHAT DO THE CEREBRO-SPINAt NERVES COMPRISE? 

The cranial nerves, those which escape from the foramina 
of the cranium, and the spinal nerves or those which are 
given off from the spinal cord. 



2 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

WHAT CONSTITUTES THE SYMPATHETIC NERVOUS SYSTEM? 

(1). A continuous chain of nerve fibres and ganglionic 
enlargements extending from the head to the coccyx on 
both sides of the spinal column, which are in constant 
communication with the cerebro-spinal nerves. 

(2). Three large gangliated plexuses situated in the 
thoracic (cardiac), abdominal (solar), and pelvic (hypo- 
gastric) cavities, 

(3). Smaller ganglia situated in the viscerae. 

(4). Numerous nerve fibres, some of which help to 
form plexuses which supply the coats of the principal 
bloodvessels and regulate their blood supply. 

The intimate connection between the cerebro-spinal and 
sympathetic nerves enables the two systems to act in 
perfect harmony. 

WHAT ARE VASO-MOTOR CENTRES? 

Within the substance of the brain and spinal cord, along 
the course of the motor and sensory nerves, are special 
centres connected with the sympathetic nerve fibres. These 
are the so-called vaso-motor centres, which have to do with 
the contraction and dilatation of tjie bloodvessels — vaso- 
constrictors and vaso-dilators. 



WHAT IS THE STRUCTURE OF A NERVE FIBRE? 

There are two kinds of nerve fibres, grey and white. 

A white fibre is made up of 

(a.) A functional element, or central axis-cylinder 
which is surrounded by a medullary sheath or the white 
substance of Schwann, composed of myelin, a liquid, fatty 
material, supported by a fine network of horny substance 
called neurokeratin. 

(b). A delicate membrane called the primitive sheath, 
or neurilemma, or sheath of Schwann, surrounding the white 
substance. 

(c). Nuclei lying at intervals beneath the sheath, be- 
tween it and the myelin. 

The white substance is interrupted at regular distances 
by what are termed nodes of Ranvier. named from the dis- 
coverer. The end of each portion, or internode, is enclosed 
in a sheath through which the axis-cylinder runs. Each 



ANATOMY AND THYSIOLOGY OF THE NERVOUS SYSTEM. 3 

internode may be conceived as a fat cell, consisting of mem- 
brane, nucleus, protoplasm and fatty matter, the cells being 
arranged end to end, and the axis-cylinder passing through 
them like a string through a series of tubular beads. 

These nerve fibres are united into fasciculi by a delicate 
nucleated connective tissue, and these in turn are connected 
into large bundles and the whole is surrounded by a dense 
connective-tissue sheath forming the nerve proper. 

The grey fibres, or non-medullated fibres, consist of an 
axis-cylinder, sheath and nuclei, but contain no myelin. 
The sympathetic nerves are made up of these fibres. 



HOW DO NERVES TERMINATE? 

Sensory nerves end peripherally in the so-called periph- 
eral end-organs in the tissues, there being three varieties, 
viz. : 

(a). The end-bulbs of Krause, found in the conjunctiva, 
the mucous membrane of the mouth and the cutis. 

(b). The tactile corpuscles of Wagner, occurring in the 
papillae of the skin of the fingers and toes; and 

(c). The Pacinian corpuscles, which are found in the 
tissues of the fingers and toes. 

Motor nerves are to be traced either into unstriped or 
striped muscular fibres. In the unstriped or involuntary 
muscles the nerves are derived from the sympathetic. Near 
their termination they divide into a number of branches 
which communicate and form an intimate plexus. From 
these plexuses are given off minute branches which divide 
and break up into ultimate fibrillae, of which the nerve is 
composed. 

Nerves supplying striped or voluntary muscles are de- 
rived from the cerebro-spinal nerves and are composed mainly 
of medullated nerve fibres. After entering the sheath of 
the muscle the nerve breaks up into fibres or bundles of fibres 
which form plexuses and gradually divide, a single nerve 
fibre, as a rule, entering a single muscular fibre. Within 
the muscular fibre the nerve terminates in a special expan- 
sion called motorial end plates. 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 



THE BRAIN. 



WHAT IS THE BRAIN? 



The brain is that portion of the central nervous system 
contained within the cranial cavity. It is composed of gray 
and white matter, the gray being external, forming the cor- 
tex or rind, and the white matter forming the internal part. 



WHAT IS THE WEIGHT OF THE BRAIN? 

The average weight of the brain in an adult male is 
about forty-nine ounces, or a little over three pounds, while 
in a female it is about forty-four ounces. Its weight in- 
creases very rapidly from the time of birth up to the seventh 



^ORTCX Ofp^ 




Fig-nre 1. 

A diagram designed to elucidate the chief component parts of the Iiuman 
brain. (Eanney.) 

year, and then more slowly to between the sixteenth and 
twentieth years, and very slowly indeed between thirty and 
forty, when it usually ceases to grow. There have been in- 
stances where the brain, as in the case of Curvier, weighed a 
a little more than sixty-four ounces, and of Abercrombie, 
sixty-three ounces, and of a mulatto whose brain weighed 
sixty-eight and three-eighth ounces. 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 5 

WHAT ARE THE PBINCIP AL DIVISIONS OF THE BRAIN ? 

(a). The cerebrum. 

(b). The cerebellum. 

(c). The medulla oblongata, and 

(d). The pons Varolii. 



THE MEMBRANES OF THE BRAIN. 

NAME THE MEMBRANES OF THE BRAIN. 

(a). The dura mater, or protecting membrane, 
(b). The arachnoid, or lubricating membrane, and 
(c). The pia mater, or nourishing membrane. 



DESCRIBE THE DURA MATER. 

It is a dense, white fibrous membrane. Its outer sur- 
face is rough and adheres closely to the inner surface of the 
skull, forming the internal periosteum. The inner surface 
is smooth. At the base of the skull it is very closely adher- 
ent, sends prolongations through the foramina, and becomes 
blended with the fibrous sheaths of the nerves and vessels 
which pass out of and into the cranial cavity. Its attach- 
ments to the periosteal ridges and the crista galli are par- 
ticularly firm. 

WHAT PROCESSES ARE FORMED BY THE DURA MATER? 

(a). The falx cerebri. 

(b). The falx cerbelli, and 

(c). The tentorium cerebelli. 

The two former processes prevent lateral oscillation of 
the cerebral and cerebellar hemispheres, while the tentorium 
forms the supporting structure of the posterior portions of 
the cerebrum and prevents it from pressing down upon the 
cerebellum. 

WHAT ARE THE ATTACHMENTS OF THE FALX CEREBRI ? 

The falx cerebri is so called from its scythe-like form. 
Its upper margin is convex and is attached to the antero- 
posterior median line of the skull as far back as the inter- 
nal occipital protuberance. It dips down between the cer- 
ebral hemispheres, being attached to the crista galli in front 
and to the tentorium cerebelli behind. Along its upper and 



6 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

lower borders two re-duplicated layers of the dura assist in 
forming the superior and inferior longitudinal sinuses. At 
its attachment with the tentorium the straight sinus is 
formed. 

WHAT ARE THE ATTACHMENTS OF THE F ALX CEREBELLI ? 

The falx cerebelli separates the two lateral lobes of the 
cerebellum. Its base is attached above to the ander part of 
the tentorium, its posterior margin to the lower division of 
the vertical crest on the inner surface of the occipital bone. 

The occipital sinuses run along its sides. 



WHAT ARE THE ATTACHMENTS OF THE TENTORIUM CERE- 

BEI.I.I ? 

The tentorium cerebelli is an arched process of the dura 
mater, elevated in the middle and inclining downward to- 
ward the circumference. It is attached behind by its con- 
vex border to the transverse ridges upon the inner surface 
of the occipital bone and encloses the lateral sinuses; in 
front it is attached to the superior margin of the petrous 
portion of the temporal bone, enclosing the superior petrosal 
sinus. 

FROM WHENCE DOES THE DURA MATER RECEIVE ITS BtOOD 

SUPPI.Y? 

The arteries of the dura mater are many, but there is 
one of special importance, the great or middle meningeal 
artery, a branch of the inferior maxillary which enters the 
skull through the foramen spinosum. 

It passes upward over the outer surface of the dura mater 
in close connection with its two veins and divides into an- 
terior and posterior branches, which are received by grooves 
in the inner table of the parietal bone. 

In almost every case of fracture of the vault of the skull 
attended with extravasation of blood it is one or the other 
of the branches of the middle meningeal artery that gives 
way. 

Other arteries which supply the dura are the lesser menin- 
geal and a small twig from the ascending pharyngeal. 
Anteriorly there are arteries from the ethmoid and internal 




Cortical Dis- 
tribution of tlie 
Middle Cere- 
bral Artery. 
(Thane and 
Charcot.) The 
remainder of 
the convexity 
is supplied by 
the anterior 
cerebral (front- 
al and mesaial) 
and the poster- 
ior cerebral. 
CENT, antero- 
lateral group of 
central arter- 
ies; 1. inf. ext. 
frontal; 2. as- 
cending front- 
al; 3. ascending 
parietal; 4, pa- 
rieto- temporal 
artery. 



Figure 2. 

The Arteries 
at the Base of 
the Brain. (Af- 
ter Thane and 
Duret, from 
Schafer.) The 
posterior cere- 
bral are cut at 
their origin 
from the bas- 
ilar. Central 
arteries (to the 
basal ganglia): 
am, antero-me- 
sial group aris- 
ing from the 
anterior - cere- 
bral ;aZ, antero- 
lateral group 
(middle cere- 
bral); pm, pi 
(on the optic 
thalamus), 
from the pos- 
terior cerebral; 
ach, pch, an- 
terior and pos- 
terior choroid- 
al arteries. 
Peripheral ar- 
teries: 1, 1, in- 
ferior internal 
frontal (ant. 
cerebr. art.); 2, 
inf. ext. front- 
al; 3, ascending 
frontal; 4, as- 
cending pari- 
etal; 5, temp- 
oro-parietal 
(middle cere- 
br.); 6. 7, 8, ant. 
post, occipital divisions from the post, cerebral arteries. 




Figure 3. 



PLATE 1. 



ANATOMY AND I»HYSIOLOaY OF THE NERVOUS SYSTEM. 7 

carotid, and posteriorly branches from the occipital, ascend- 
ing pharyngeal and vertebral arteries. 



WHAT SERVES SUPPLY THE DURA MATER? 

The recurrent branch of the fourth, some filaments from 
the Gasserian ganglion, the ophthalmic, the hypoglossal and 
the sympathetic. 

DESCRIBE THE ARACHNOID MEMBRANE. 

A thin, delicate membrane investing the brain beneath 
the smooth, inner surface of the dura mater. On account 
of its extreme thinness it has been named the arachnoid, 
from the Greek word denoting a spider's web. It is called 
the lubricating membrane because it throws out a serous 
fluid upon its surface, which allows of slight movement of 
the brain against the surface of the dura mater with very 
little friction and consequent irritation. 



WHAT SPACES ARE FOUND BETWEEN THE MEMBRANES ? 

The sub-dural space, which contains a small quantity of 
fluid; the arachnoid covers the pia mater very closely, but 
it does not dip down into any of the sulci of the brain; 
upon the convex surface the arachnoid and pia mater can 
not be readily separated. But there are places, especially at 
the base of the brain, called the sub-arachnoid spaces, where 
the two membranes are separated to a greater or less degree. 



WITH WHAT ARE THE SUB- ARACHNOID SPACES FILLED ? 

These spaces are filled with a fluid called cerebro-spinal, 
which acts as a cushion for the brain, thus preventing any 
serious effects from ordinary concussion. 

The amount of fluid in these spaces is much more than 
in the sub-dural spaces, but the whole amount outside of 
the brain is about two ounces, it communicating with the 
fluid within the ventricles of the brain through the foramen 
of Magendie. 

The brain is, therefore, supported by this fluid, which in- 
sinuates itself into all the inequalities of the surface and 
most effectually protects it. 

In cases of fracture of the base of the skull involving 



8 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

the petrous portion of the temporal hone the escape of this 
fluid through the ear is a diagnostic feature. 



WHAT NERVES SUPPLY THE ARACHNOID? 

The nerves of the arachnoid are filaments from the 
motor root of the fifth nerve, the seventh and the eleventh 
nerves. 

DESCRIBE THE PIA MATER. 

The true nourishing membrane of the brain, immedi- 
ately investing it. It is extremely vascular, being com- 
posed of a minute network of bloodvessels held together 
by a very delicate areolar tissue. It covers the entire brain, 
dips down between the convolutions and sends prolonga- 
tions into the interior, forming the velum interpositum and 
choroid plexus of the fourth ventricle. 

On the surface of the cerebrum it is very vascular and 
gives off from its under surface a large number of minute 
vessels which extend perpendicularly into the cerebral sub- 
stance. Upon the surface of the cerebellum it is thinner 
and not so vascular, and on the pons Varolii and medulla it 
is more fibrous and less vascular than elsewhere. 



WHAT VESSELS SUPPLY THE PIA MATER? 

Its derives its blood from the internal carotid and ver- 
tebral arteries. 

WHAT NERVES SUPPLY THE PIA MATER? 

The third, fifth, sixth, seventh, ninth, tenth, eleventh 
and sympathetic nerves, which chiefly accompany the blood- 
vessels. It is important that special note be taken of the 
nerve-supply of the membranes of the brain, for many 
headaches are due to meningeal irritation, and the location 
and character of the pain will often give a clew to the di- 
agnosis. 

THE CEREBRUM. 

DESCRIBE THE CEREBRUM. 

It is the larger part of the brain, filling the whole upper 
portion of the cranial cavity and overlying all other por- 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 9 

tions of the brain. It rests in the anterior and middle fos- 
sa? of the base of the skull, and is separated posteriorly 
from the cerebellum by the tentorium cerebelli. It- is di- 
vided into two lateral hemispheres by the great longitudi- 
nal fissure, which extends throughout its entire length. 
The hemispheres are unequal in size, the left being usually 
the larger. This has been attributed to the more direct 
blood supply to the brain on that side, the left vertebral and 
carotid arteries having independent origins from the arch 
of the aorta. The hemispheres are joined together by a 
broad transverse commissure of white matter called the 
corpus callosum. Each hemisphere presents a convex outer 
surface which corresponds with the inner surface of the 
cranium, an inner surface which is flat and in contact with 
the opposite hemisphere, and an under surface which is ir- 
regular, as it rests upon the bones at the base of the skull. 



WHAT IS TO BE SEEN UPON THE CONVEX SURFACE OF THE 

HEMISPHERES ? 

The surface of each hemisphere presents a large num- 
ber of convoluted eminences, the convolutions or gyri, 
which are separated from each other by depressions, called 
fissures or sulci, of various depths. The surfaces of these 
convulutions are composed of gray matter, the interior be- 
ing of white matter. They are formed to increase the 
amount of gray matter within the cranial cavity without 
occupying additional space, so that its actual surface is 
nearly six times what it w^ould be if it were merely a smooth 
envelope. Usually the larger the number of convolutions, 
and, consequently, the larger the extent of gray matter, the 
greater the intellectual capacity; but this is not always so, 
as in some cases the quality of the gray matter is to be con- 
sidered more than the quantity. The sulci are generally 
about an inch in depth. They vary in different brains and 
in different parts of the same brain. The hemispheres are 
divided into lobes and lobules by deep fissures. 



DESCRIBE THE FISSURES OF THE CEREBRUM. 

(a). Fissure of Sylvius. — This fissure begins at the 
base of the brain, at the posterior boundary of the anterior 



10 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

fossa of the skull, and divides into two branches, one passing 
upward toward the longitudinal fissure, called the ascending 
limb, and the other, the longer one, called the horizontal 
limb, running horizontally backward^ usually terminating in 
the parietal lobe in a bifid extremity. The branches of the 
fissure of Sylvius originate from the development of the 
hemisphere around the central lobe, or insula, which is 
usually covered in. The portion of the hemisphere over- 
lapping the central lobe is called the operculum, from its 
lid-like character. The fissure of Sylvius is the most con- 
spicuous of the cerebral fissures and is easily recognizable. 
It is of great surgical and medical importance, because it 
contains the middle cerebral artery, which is particularly 
liable to obstruction from an embolus. 

(b). Fissure of Rolando. — The fissure of Rolando be- 
gins near the longitudinal fissure on the upper surface of 
the brain, a little posterior to the middle, and runs obliquely 
over the convex surface of the hemisphere at an angle of 
about sixty-seven and one-half degrees, downward and for- 
ward almost to the junction of the two limbs of the fissure 
of Sylvius. This fissure is of special importance because it 
is situated in the middle of the motor area of the brain and 
constitutes, with the Sylvian fissure, the principal landmark 
used in cerebral localization. 

(c). Parieto-Occipital Fissure.— The parie to-occipital 
fissure is situated partly upon the outer hemisphere, where 
it is called the external parieto-occipital fissure to distin- 
guish it from that portion which is seen upon the inner 
surface and called the internal parieto-occipital fissure. It 
begins at the calcarine fissure, near the corpus callosum, 
and ascends vertically, ending on the external surface about 
an inch below the longitudinal fissure. 

(d). Calloso-Marginal Fissure. — This fissure is above 
the gyrus fornicatus on the inner surface of the hemisphere. 

(e). Calcarine Fissure. — The calcarine fissure begins 
near the posterior border of the hemisphere, passes forward 
and ends under the corpus callosum, penetrating into the 
posterior horn of the lateral ventricle. It joins the parieto- 
occipital fissure midway. 

(f). HiPPOCAMPAL Fissure. — The hippocampal fissure is 
seen upon the inner surface of the cerebral hemisphere and 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. H 



indicates the seat of a convolution known as the "hippo- 
campus major." 

(g). Transverse Fissure. — The transverse fissure sepa- 
rates the cerebrum from the cerebellum. It is continuous 
with the lateral and third ventricles and admits the pia 
mater into the interior of the brain to form the velum 
interpositum. 

(h). Parietal Fissure. — The parietal fissure is some- 
times connected with the parieto-occipital, and sometimes 
with the horizontal portion of the fissure of Sylvius; but 




Fig-ure 4. 
A diagram sliowing the convex surface of the cerebrum. (Dalton.) 
S, fissure of Sylvius, witli its two brandies, a and b, b, b. R, fissure of Ro- 
lando. P, Parieto-occipital fissure, 1, 1. 1, the first or superior frontal convolu- 
tion, 2. 2, 2, 2, the second or middle frontal convolution. 3. 3, 3, the third frontal 
convolution, curving around the ascending limb of the fissure of Sylvius {motor 
center of speech). 4. 4. 4, ascending frontal (anterior central) convolution. 5. 5, 
5, ascending parietal (posterior central) convolution. 6, 6, 6, supra-marginal con- 
volution (parietal lobule), which is continuous with 7, 7, 7, the first or superior 
temporal convolution. 8, 8, 8, the angular convolution (or gyrus), which becomes 
continuous with 9, 9, 9, the middle temporal convohition. 10, the third or inferior 
temporal convolution. U, 11, the superior parietal convolution. 12, 12, 12, the 
superior, middle and inferior occipital convolutions. 

generally it begins between the latter and the fissure of 
Rolando and curves backwards parallel with the superior 
border of the cerebrum. (Fig. 4.) 

NAME AND LOC.^TK THE LOBES .\ND PRINCIPAL CONVOLU- 
TIONS OF THE CEREBRUM. 

Frontal Lobe. — The frontal lobe is that portion of the 
cerebrum situated in front of the fissure of Rolando, and 



12 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

above the fissure of Sylvius. It is divided into four con- 
volutions or gyri. 

Tlie ascending frontal convolution or gyrus is situated 
just anterior to the fissure of Rolando. It is sometimes 
called the precentral gyrus. 

The superior frontal convolution joins the ascending 
frontal and passes forward across the frontal lobe, horizontal 
to the longitudinal fissure. It borders on the anterior part 
of the corpus callosum internally and extends to the under 
surface, where it forms the olfactory lobe. 

The middle frontal convolution passes parallel to the 
superior. 

The inferior frontal convolution is below the preceding 
and in relation to the fissure of Sylvius. The left inferior 
frontal convolution is often called Broca's convolution or 
the speech centre, from the localization of the movements 
of the lips and tongue in articulation, in its posterior portion. 

Parietal Lobe. — The parietal lobe is situated posterior 
to the fissure of Rolando and extends back to the parieto- 
occipital fissure. It is bounded below by the horizontal 
limb of the fissure of Sylvius which separates it from the 
temporo-sphenoidal lobe. It has also four convolutions. 

The ascending parietal convolution or post-central is 
posterior to the fissure of Rolando and usually extends 
under it joining the ascending frontal. The two convolu- 
tions thus surround the fissure of Rolando and also form 
what is called the opercular lobe. 

The superior and inferior parietal convolutions are sepa- 
rated by the parietal fissure and are usually continuous 
with the occipital lobes by bridges of gray matter called 
aunectant convolutions. 

The superior marginal convolution blends with the 
lower part of the posterior central gyrus and arches over 
the end of the horizontal branch of the fissure of Sylvius to 
join the superior temporo-sphenoidal convolution. 

The angular convolution is behind the supramarginal 
and parallel to the fissure of Sylvius. It usually joins the 
temporo-sphenoidal and occipital lobes by annectant bands. 
Upon the median surface the superior parietal convolution 
joins with the upper extremity of the posterior central con- 
volution to form the precuneus, or quadrate lobe. 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 13 

Occipital Lobe. — The occipital lobe presents three prin- 
cipal convolutions, which are usually badly defined, the supe- 
rior, middle and inferior. These are subdivided by the occip- 
ital fissure and are continuous with the convolutions of the 
parietal and temporal lobes. Upon the median surface the 
superior occipital convolution, somewhat triangular in shape, 
forms the cuneus lobule, placed between the parieto-occipital 
and calcarine fissures. 

Temporo - Sphenoidal Lobe. — The temporo - sphenoidal 
lobe presents three well-marked convolutions which run in 
an antero-posterior direction. 

The superior lies below the horizontal limb of the Syl- 
vian fissure and is continuous behind with the parietal lobe. 

The middle becomes continuous with the angular gyrus 
and is connected with the third occipital convolution. 

The inferior is seen on the under surface of the cerebrum 
and is also connected with the third occipital convolution. 

Limbic Lobe. — The limbic lobe when described separately 
includes the gyrus fornicatus, or convolution of the corpus 
callosum, which begins just in front of the anterior perfor- 
ated space at the base of the brain, ascends in front of the 
genu of the corpus callosum, and runs backward along the 
upper surface of this body to its posterior extremity, where 
it passes downward and forward under the name o^ the gyrus 
hippocampi to terminate in the uncinati gyrus, nearly oppo- 
site to where it began. 

NA3IE AND LOCATE THE LOBULES OF THE CEKEBRU»I. 

(a). The island of Reil or lobulus centralis lies deeply 
situated in the commencement of the fissure of Sylvius. It 
can only be seen by the separation of the lips of that fissure. 
It is a triangular eminence and 'consists of from four to six 
small convolutions, gyri operti, arranged side by side, and 
appearing when exposed very much like the finger of the 
hand when closed upon the palm. It covers the lenticular 
nucleus of the corpus striatum. Behind the central lobe 
there are usually several small convolutions, known as the 
temporo-parietal or retro-insular convolutions. 

(b). The para-central lobule is seen on the inner sur- 
face of the cerebrum, anterior to the calloso-marginal fissure. 
(Fig. 5.) 



14 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM, 

(c). The lobulus quadratus lies just posterior to the 
para-central lobule and extends back to the parieto-occipital 
fissure. 

(d). The lobule -cuneus is a wedge-shaped body which 
lies between the parieto-occipital and calcarine fissures, on 
the inner surface of the cerebrum. 



WHAT IS THE MICROSCOPICAL ANATOMY OF THE CORTEX? 

The cortex of the cerebrum is composed of nerve cells, 
a net-work of nerve fibres, processes and neuroglia tissue. 




Figure 5. 

A diagram showing a longitudinal median section of the cerebrum. (Dalton). 

1, calloso-marginal fissure. 2. parieto-occipital fissure. 3. calcarine fissure. 
A, third ventricle. B, fifth yentricle. D, anterior crura of fornix. C, cuneus (oc- 
cipital lohule). Q, precuneus (lobulus quadratus). P, para-central lobe. C, C, 
corpus callosum. F, gyrus fornicatus. 

the latter being an intercellular substance which serves to 
cement the cells and to maintain a fixed position for them, 
as well as to furnish passage for the vessels of nutrition of 
the cells. These elements are formed into layers which are 
never strictly defined, as the elements of one layer inter- 
penetrate a little to the regions of other layers. 

Allowing for this we recognize the following cortical 
layers in the Kolandic area: 

(a). The first or molecular layer, containing but few 
cells, Its outermost layer is formed of neuroglia cells. 

(b). The second layer of cells, sometimes fusiform, 
sometimes pyriform, and again triangular or polygonal, in- 
terspersed with a large number of small pyramidal cells. 

(c). The third layer of pyramidal cells, with long and 
short apical processes. The pyramidal -cells with short 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 15 

apical processes are scattered about throughout all the 
cortex below the molecular layer, and show no special 
gradation in size. None of their apical processes pass into 
the molecular layer, their terminations being always deeper. 
They are a different system of cells from the pyramidal 
cells with long apical processes, for the latter always reach 
up to and end in the molecular layer. They also increase 
in size of cell body from above downward. 

(d). The fourth layer of polymorphic elements, in 
which the following are the main cell types : (1 ) . Pyramidal 
cells with short apical processes. (2). Granule cells. Both 
of these may interpenetrate a little distance into the super- 
adjacent layer. (3). Fusiform cells proper, with ascending 
axis-cylinder processes. (4). Fusiform cells with descend- 
ing axis-cylinder processes passing into the white substance. 
(5). Asymmetrical or oblique pyramidal cells intermediate 
between the strictly fusiform and the pyramidal. (6). In- 
verted pyramidal cells. (7). Cells with short branching 
axis-cylinders, and cell body of polygonal shape. 

Various types of cortex are described, depending upon 
the different degree of development of the cell layers and 
upon the fibre arrangements. The common or motor type 
has four layers. The large pyramidal cells are numerous 
and are arranged in clusters. The sensory type has at least 
five layers, the fifth a subdivision of the fourth; and here 
the large pyramidal cells are few and isolated. The basil 
processes of the pyramidal cells are continued as axis- 
cylinders. Some pass down into the white matter, and 
others turn up and enter the fibre system of the cortex. 

To sum up, then, there are, according to Andriezen, four 
layers fundamental to the cortex in the Rolandic area: 
(1). Molecular. (2). Ambiguous, {d). Long pyramidal. 
(4). Polymorphic. Of the various cells entering into the 
constitution of these there are eight t3^pes: (1). The 
pyramidal cell with long apical process reaching to the 
molecular layer. (2). The pyramidal cell with short apical 
process not reaching to the molecular layer. (3). The am- 
biguous cell, whose sub-types may be asymmetrical, bicornate, 
globose, pisiform, etc. (4). Granule cell. (5). The fusi- 
form or triangular cell, with ascending axis-cylinder process. 
(6). The fusiform, cell, with descending axis-cylinder process. 



16 



ANATOMY AND PHYSIOLOGY OF THE NEKVOUS SYSTEM. 



(7). The oblique and inverted pyramidal cell, with descend- 
ing axis-cylinder. (8). The pol3^gonal cell, with short 
branching axis-cylinder, the sensitive cell of Golgi. 

These cells are not only distinguished by their morphol- 
ogy but by their anatomico-physiological connections, as 
well. Some of them receive nervous impulses from other 
cells and from terminal nerve fibres coming in from the 




Figure 6. 

The under surface of the brain. (Hirschfeld). 

1, 1, anterior lobe of the cerebrum. 2, splienoidal portion of tlie posterior lobe. 
4, anterior extremity of tlie median lissure. 5, posterior extremity of the same. 
6, 6, fissure of Sylvius. 7, anterior perforated space. 8, tuber cinerum and pitui- 
tary body, 9, corpora albicanlia. 10, posterior perforated space. 11, crura cerebri. 
12, pons Varolii. 14, medulla oblongata. 14, anterior pyramids. 15, olivary body. 
16, restiform body ^'only partially visible). 17, 17. hemispheres of the cerebellum. 
18, fissure separating these hemispheres. 19, 19. first and second convolutions of 
the frontal lobe with the intervening sulcus. 20, external convolutions of the 
frontal lobe. 21, optic tract. 22, olfactory nerve. 22, section of olfactory nerve, 
showing its triangular prismatic shape; the trunk has been raised to show tlie 
sulcus in which it is lodged. 23, ganglion of the olfactory nerve. 24. optic chiasm. 
25, motor oculi. 26, patheticus. 27, trigeminus. 28, abducens. 29, facial. 30, 
auditory nerve and nerve of Wrisberg. 31, glosso-pharyngeal. 32, pneumogastric. 
33, spinal accessory. 34, hypo-glossal. 

white matter. Others associate and co-ordinate these im- 
pulses, and still others discharge them. The processes of 
these cells are interwoven with each other and with white 
fibres, forming a close network over the whole brain. An 
enormous number of fine fibres are given off by the cells. 
Some connect neighboring parts, others distant parts, and 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 17 

some pass to lower levels. There would seem to be three 
kinds of fibres — afferent, associative and efferent. 

It will thus be seen that the cerebral cortex contains 
layers of nerve cells, into which nerve fibres penetrate. 

The cortex has been likened to the cells of a battery, 
which generate and store electricity and discharge it under 
proper conditions. 

Nerve-force is the energy which the cortical cell generates 
and gives off by means of the processes and nerve fibres con- 
nected tvith it. 

The cortex is from two to four millimetres in thickness, 
and spreads over the whole surface of the cerebrum. It dips 
down into the convolutions and everywhere covers the white 
matter. The whole functional activity of the brain is cen- 
tered in the cortex; so it can be readily seen of what great 
importance it is to the human economy. 



WHAT POINTS ARE IN VIEW ON THE UNDER SURFACE OF THE 

CEREBRUM? 

(a). From before backward, the anterior portion of the 
longitudinal fissure, which partially separates the two hem- 
ispheres. (Fig. 6). 

(b). The corpus callosum, or the great transverse com- 
missure, which is a thick stratum of transverse fibres ex- 
posed at the bottom of the longitudinal fissure. It connects 
the two hemispheres of the brain and forms the roof of a 
space in the interior of each hemisphere, called the lateral 
hemisphere. It is four inches in length and extends within 
an inch and a half of the anterior and within two inches 
and a half of the posterior part of the brain. Anteriorly it 
curves downward to reach the base of the brain, forming 
the " genu," and posteriorly it dips down to form the 
splenium. The fibres of the callosum may be traced to the 
white substance of the cerebral hemispheres, the gyrus for- 
nicatus, the fornix, the occipital lobe and the temporo- 
sphenoidal lobe. The fibres are both longitudinal and 
transverse, and serve to unite component parts of the cere- 
bral hemispheres. The transverse fibres pro])ably unite 
homologous parts of each hemisphere. 

(c). The lamina cinerea, a thin layer of gray tissue ex- 
tending from the corpus callosum to the optic commissure. 



18 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 



(d). The fissure of Sylvius, between the frontal and 
middle lobes. 

(e). The anterior perforated space or vallecula, through 
which the vessels that supply the corpus striatum pass. 

(f). The olfactory bulbs and the olfactory tracts, which 
lie in a straight furrow on the orbital surface of the lobe 
and give origin to the olfactory nerves. 




Fig-ure 7. 
1, frontal lobe. 2, sphenoidal lobe. 3, 3, convolution of the corpus callosum. 
4, 4, convolutions of the parietal lobe of the internal surface. 5, 5, convokitions of 
the frontal lobe. 6, convolutions of the occipital lobe. 7, sulcus separating the 
parietal from tlie occipital lobe. 8, sulcus separating the frontal from the parietal 
lobe. 9. section of the corpus callosum. 10, genu of the corpus callosum. 11, ros- 
trum of the corpus callosum. 12, posterior extremity of the corpus caHosmn. 13, 
fornix. 14, section of the fornix. 15. left anterior crus of the fornix, passing into 
the internal wall of the optic thalamus, to reach the corresponding corpus albicans— 
course indicated by a dotted line. 16, foramen of Monro. 17, corpus albicans, in 
which the anterior crus of the fornix bends ui)on itself, in the form of a figure of 
eight, to be lost in the substance of the optic thalamus. 18, septum lucidum. 19, 
section of the choroid plexus, 20, pineal gland. 21. left superior peduncle of tlie 
same. 22, section of tlie gray commissure of the third ventricle. 23, tuburcula 
quadrigemina, above which are seen tlie pineal gland with its inferior peduncle 
and the posterior commissure. 24, section of the anterior commissure. 25, aque- 
duct of Sylvius. 2G. section of the valve of Vieussens. 27, fourth ventricle. 28,28, 
section of the middle lobe of the cerebellum 29, arbor vitiie. 30. corpus cinreum. 
31, pituitary body. 32, optic nerve. 33, pons Varolii. 34, medulla oblongata. 

(g). The optic commissure, formed by the union of the 
optic tracts. 

(h). The tuber cinereum, the gray prominence behind the 
optic commissure, which is the floor of the third ventricle, 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 19 

from which projects a red-colored conical tube, the infundi- 
bulum, to which is attached the pituitary body (a small, red- 
dish-gray vascular mass consisting of two lobes), which is 
lodged in the sella turcica of the sphenoid bone. 

(i). The corpora albicantia, two white rounded bodies 
behind the tuber cinereum, formed by the bulbs of the 
fornix, a commissure situated beneath the corpus cal- 
losum, but continuous with it posteriorly. Each lateral 
half of the fornix presents an anterior pillar or crus, whose 
fibers pass downward and then after twisting in a figure of 
eight manner pass upward to end in the optic thalami, and 
a posterior pillar, which enters the middle horn of the lat- 
eral ventricle. (Fig. 7). 

(j). The posterior perforated space, a gray depression pos- 
terior to the corpora albicantia, perforated by vessels which 
supply the optic thalami. 

(k). The crura cerebri or cerebral peduncles, two thick 
cylindrical bundles of white matter which emerge from the 
anterior border of the pons and diverge as they pass for- 
ward and outward to enter the under part of each hemi- 
sphere. Each crus consists of a superficial and deep layer 
of longitudinal white fibres separated from each other by 
the substantia nigra or locus nigra, a mass of gray matter 
containing small multipolar ganglion cells. The super- 
ficial layer is called the crusta or basis cruris, and conducts 
motor fibres, the deep layer or tegmentum cruris conduct- 
ing sensory fibres. 

THE BASAL GANGLIA. 

WHAT ARE THE BASAL. GANGLIA? 

Two nodal masses of gray matter situated within the 
substance of each cerebral hemisphere and resting nearly 
upon the floor of the cerebrum. 

The anterior mass is called the corpus striatum, from 
the striated appearance of a section made through its sub- 
stance. 

The posterior mass is called the optic thalamus, from its 
supposed association with vision. 



INTO WHAT IS THE CORPUS STRIATUM DIVIDED? 

Each corpus striatum is divided by the fibres of the so- 
called internal capsule into two distinct portions, one of 



20 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

which projects into the lateral ventricle while the other 
does not. 

The first portion is known as the intra-ventricular por- 
tion, or the caudate nucleus, an ovoid-pyriform body, its 
base toward the frontal lobe, and a "tail-like'' portion which 
passes up over the optic thalamus which lies just behind it, 
investing it like a surcingle. 

The other portion is shaped somewhat like a lens and 
lies buried within the substance of the hemisphere. It is 
called the lenticular nucleus, or extra-ventricular portion. 



WHAT FIBRES COMPOSE THE CORPUS STRIATUM? 

(1). Fibres which pass to it from the cortex (afferent). 

(2). Fibres which pass through it from the frontal and 
parietal cortex. 

(3). Fibres which originate in it (efferent), and 

(4). Fibres connecting its different parts. 

The afferent fibres are in five groups: (1). Those 
which spring from the entire arch of the cerebral hemis- 
phere, corona radiata. (2). Fibres springing from the 
temporal lobe to the most anterior part of the caudate 
nucleus, stria cornea. (3). Fibres which arise from the 
olfactory lobe. (4). Fibres from the septum lucidum; and 
(5). Fibres from the cerebellum. 

The efferent set comprise those fasciculi which help to 
form the cerebral peduncles and which are dispersed after 
having passed through the pons Varolii, chiefly in the dif- 
ferent segments of the spinal cord. 



WHAT ARE THE FUNCTIONS OF THE CORPUS STRIATUM? 

It is a ganglion in which cerebral, cerebellar and spinal 
activities are brought into intimate communication; it is a 
halting-place for voluntary motor impulses emitted from 
the cerebral cortex, and serves as a modifier of all motor acts. 



DESCRIBE THE OPTIC THALAMI. 



These ganglia are situated posterior and interior to the 
corpora striata. They are continuous with each other by 
means of the middle commissure. The upper surface forms 
part of the walls of the lateral ventricles; the mesial sur- 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 21 



face forms the lateral wall of the third ventricle. They are 
oval-shaped masses of gray substance, covered superficially 
by a thin layer of white substance. 

Upon the anterior part is a prominence called the an- 
terior tubercle , and at the posterior and inner surface is the 
posterior tubercle, or pulvinar. 

Below and external to the pulvinar and continuous with 
the gray matter of the optic thalamus is the outer geniculate 
body, and below that the inner geniculate body. The optic 



Ant. tubercle 



PEDUNCLE Of 
PINEAL GLAND 



LAMINA 
CiNEREA 




-PUiVlNM 



PINEAL 
-10 GLAND 



Figure 8. 

The inner surface of the optic thalamus, the third ventricle, and neighboring 
parts. (Ranney). 

Th. sup., superior part of thalamus. Th. inf., inferior part of the same. m. c, 
middle commissure. 1. section of optic commissure. 2, infundibulum and pitui- 
tary body. 3. anterior commissure of third ventricle. 4. anterior crus of fornix. 
5, corpora albicantia candicans. G, anterior crus of fornix. 7, the third nerve. 8, 
crus cerebri. 9, pons Varolii. 10, posterior commissure. 11. corpora quadrig- 
emina. 12, aqueduct of Sylvius. 13, fourth ventricle. 14, third ventricle. 

tracts wind around the posterior and outer edge of the 
thalamus. 

The external surface lies in contact with the internal 
capsule of the cerebrum, and along this surface radiating 
fibres pass out and join the fibres of the internal capsule, to 
be distributed to the cerebral cortex. Fibres are also sent 
to the optic tract and to the tegmentum or cruris. 



2';i 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 



WHAT GANGLIA ARE FOUND IN THE OPTIC THALAMUS? 

Four isolated ganglia are demonstrated in the thalamus. 

The first, or anterior, has to do with the sense of smell 
and is called the olfactory centre. 

The second, or middle, is the optic centre and receives 
fibres from the optic tracts. 

The third, or median, ganglion is called the sensory 
centre, as it presides over sensation. 

The fourth, or posterior, is the acoustic centre. (Fig. 8). 



WHAT IS THE INTERNAL CAPSULE ? 



It is a tract of fibres which separates the lenticular nu- 
cleus and the thalamus, forming a capsule to the former. 




Figrure 9. 

Showing the relation of the internal capsule of the cerebrum to adjacent 
structure; viewed from above. (Ranney). 

The section of the brain has been made horizontally in a plane to intersect 
the basal ganglia. C, N. caudate nucleus af the corpus striatum. L, IV, lenticular 
nucleus of the same with its three parts (a, h. c). O. T, optic thalamus. S. fossa 
of Sylvius, c, claustrum. E, C, external capsule of cerebrum, j, ('. /, convoUi- 
tions of the Island of Reil. a, &, c, the inner, middle and external member of the 
lenticular /lucleus. l, anterior limit of the internal capsule. 2. "knee" or bend 
of the same. 3, posterior limit of the same. 1-2, "caudo-lenticular'" portion of 
the capsule. 2-3, " thalamo-lenticular " portion of the same. F, crura of fornix, 
the fifth ventricle lying in front, and the third ventricle behind it. s, I, septum 
lucidum. showing its two layers with the fifth ventricle between them, m, c. mid- 
dle commissure of the thalamus, p, pineal gland and its pedimcles. n, nates cere- 
bri, t, testes cerebri. 

W HAT DOES IT CONTAIN? 

(1). Pyramidal fibres which control voluntary movements 
of the limbs. (2). A sensory tract, which conveys sensations 
from the surface of the body to the cortical cells. (3). The 
speech tract. (4). Face fibres — motor. (5). Special sense 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM.. 23 

fibres — sight, smell, hearing, taste and touch. (6). The 
hypoglossal tract. 

There is an angle in the formation of the internal cap- 
sule, at about its centre, called the knee. That portion of 
the internal capsule anterior to the knee, between the len- 
ticular and caudate nuclei, is called the caudo-lenticular por- 
tion; that lying posterior to the knee is called the thalamo- 
lenticular portion, and it is this latter portion through which 
the bundles of fibres just mentioned passes. These fibres in 
the anterior portion are not yet thoroughly understood. A 
similar tract of fibres to the internal capsule, called the ex- 
ternal capsule, separates the lenticular nucleus from the 
claustrum. The internal capsule seems to be a continuation 
upward into the cerebral hemispheres of both the motor and 
sensory portions of the crus, where its fibres diverge and 
form the greater part of the "corona radiata" which pass to 
the convolutions. It has no structural relation to the basal 
ganglia although it passes through them. (Fig. 9). 



AVHAT AKE THE CORPORA QUADRIGEMINA ? 

Four rounded bodies, mainly composed of gray matter, 
arranged in pairs, two in front and two behind, situated im- 
mediately behind the third ventricle and above the aque- 
duct of Sylvius. The anterior pair are the larger, are of 
gray color and are called nates; the posterior pair, lighter in 
color, are called the testes. They are connected on each side 
with the optic thalamus and optic tracts by two white bands 
termed the brachia, those connecting the nates with the 
thalamus being called the anterior brachia, while those con- 
necting the testes with the thalamus are called the posterior 
brachia. They are also connected with the cerebellum by 
means of a large white cord on either side called the pro- 
cessus e cerebelli ad testes, or superior peduncles of the cer- 
ebellum.5 

WHAT ARE THE FUNCTIONS OF THE CORPORA QUADRIGEMINA ? 

It is believed there is a centre within the nates which 
controls the accommodation of vision for near objects, as 
well as the coordination of all ocular movements. The con- 
nection of these bodies with the optic thalami and the optic 
tracts would lead us to suppose that this might be true. It 



24 . ANATOMY AND PHYSIOLOGY OF THE NEKVOUS SYSTEM. 




^...r,X2 



Fig-ure 10. 

A diagram showing the general arrangement of the fibres of the cerebro-spinal 
system. (Ranney. modifled from Landois). 

The sliaded portions represent tlie collections of gray matter. On tlie left side 
of the diagram the sensory fibres of the crus are tracetl upward from the spinal 
cord to different portions of the cerebrum; on the right side the motor fibres are 
similarly represented. Numerals are used hi designating the sensory and com- 
missural fibres; the motor fibres are lettered in small type. The cortical layer 
is shown at the periphery of the cerebral secticm. with commissural fibres \l) 
connecting liomologous regions with the hendspheres, and associating fibres 
(a. s). connecting difierent convolutions of each hemisphere. (\ N. caudate 
nucleus of the corpus striatum. L, N, lenticular nucleus of the same. O. T, 
optic thalamus of each hemisphere, united to its fellow in the median line, 
e, q, corpora quadrigemina, c, I, claustrum, lying to the right of the letters. 
c, c, corpus callosum. with its commissural fibres. S, fissure of Sylvius. Y, 
lateral ventricle, the fifth ventricle being shown between the two layers of the 
septum lucidum. ('. tlie motor tract of the crus cerebri (basis cruris.. crusta). 
T, the seusatory tract of the crus cerebri (tegmentum cruris). Cf, the cere- 
bellar fasciculus, which is turned to the right for perspicuity, but which in 
reality decussates, e, the point of decussation of the motor fibres of the spinal 
cord. /, tlie course of the motor fibres of the spinal cord below the medulla, 
showing their coimection with the cells of the anterior horns of the gray mat-^ 
ter, and their continuation into the anterior roots of the spinal nerve Cq)' «.. 
fibres wliich radiate through the caudate nucleus, b, fibres of the "internal 
capsule." c. fibres which radiate through the lenticular nucleus, d, fibres of 
the "external capsule," 2, a, 4, 5, G, 7, 8. 9, sensatory fibres radiating from the 
tegmentum cruris to the cortex by means of various nodal masses of gray mat- 
ter. 11, course of the sensatory fibres of the spinal cord (shown by dotted lines), 
intimately connected with the posterior root ot the spinal nerve (i-M. and decus- 
sating at or near the point of entrance into the spinal cord. 



ANATOMY AND THYSIOLOGY OF THE NERVOUS SYSTEM. 25 

also undoubtedly intensifies the inhibitory or controlling 
influence of the brain upon the reflex actions of the spinal 
cord. 

WHAT AND WHERE IS THE PINEAI. GI.AND ? 

It is shaped like a fir-cone, pums, hence its name. It 
is a small reddish-gray body, placed immediately behind 
the posterior commissure and between the nates, upon which 
it rests. It is joined to the cerebrum by tw^o peduncles 
called the superior and inferior peduncles of the pineal 
gland. It is regarded as one of the ganglia of origin of the 
tegmentum cruris, since it is connected with the crus by 
means of the posterior commissure of the third ventricle. 



THE CENTRUM OVALE. 

OF WHAT DOES THE INTERIOR OF THE CEREBRUM CONSIST? 

Of an oval-shaped centre of white substance surrounded 
on all sides by a. narrow, convoluted margin of gray matter 
which presents an equal thickness in nearly every part. 
This white-central mass is called the centrum ovale, and is 
formed of nerve fibres which connect various parts of the 
brain with each other. 



HOW MANY SETS OF THESE FIBRES ARE THERE ? 

Four. The first spring from the cortex, cross over to the 
opposite hemisphere by means of the corpus callosum, to 
connect homologus regions of the cortex of the two hem- 
ispheres. They are- called commissural fibres, and consti- 
tute the transverse fibres of the corpus callosum. The second 
set arise from the cortex, accompany the commissural fibres 
for a short distance and then separate without passing to 
the opposite hemisphere, some passing into the basal gang- 
lia, others going to form the internal and external cap- 
sules. They are called radiating fibres, or corona radiata. 
The third set connect different portions of the cortex of the 
same hemisphere, and are called associating fibres. The 
fourth seb connect the cortex of the temporo-sphenoidal 
lobes with the optic thalami, and constitute the so-called 
fornix fibres. (Fig. 10). 



26 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

THE CEREBELLUn. 

WHAT IS THE CEBKBELLUM AND WHEKK IS IT SITUATED? 

The cerebellum, or little brain, is tliat portion of the 
encephalon contained in the inferior occipital fossae. It is 
situated beneath the posterior lobes of the cerebrum, from 
which it is separated by the tentorium. Its average weight 
is about five ounces. In form it is oblong and flattened 
from above downward, its greatest diameter being from 
side to side. It is composed of gray and white matter, the 
gray matter occupying the surface, as it does in the cere- 
brum. The surface of the cerebellum is not convoluted like 
the cerebrum, but has numerous curved furrows or sulci. 



WHAT ARE THE DIVISIONS OF THE CEREBELLUM ? 

It is divided into two hemispheres and a central portion 
called the vermiforhi process. 

Upon the upper surface of each hemisphere there are 
two lobes: the anterior or square lobe, and the posterior or 
semi-lunar lobe. Upon the surface there are five lobes; the 
flocculus or sub-peduncular, the amygdala or tonsil, the di- 
gastric, the slender, and the inferior posterior lobe. 



AVHAT KIND OF FIBRES ARE FOUND IN THE CEREBELLUM? 

The peduncular fibres, which form the peduncles of the 
cerebellum, and the fibres proper of the cerebellum. 



WHAT ARE THE PEDUNCLES OF THE CEREBELLUM? 

They are bundles of fibres which connect the cerebellum 
with other portions of the brain. There are three of these 
bundles, called the superior, middle, and inferior peduncles. 

The superior peduncles (processus e cerebelli ad testes) 
arise from the middle of the white matter of the cerebral 
hemispheres, pass beneath the testes of the corpora quadri- 
gemina, and run outward and backward to the cerebellum. 

The middle peduncles (processus ad pontem) connect 
the two hemispheres of the cerebellum, forming their great 
transverse commissure. 

The inferior peduncles (processus ad meduUam), connect 
the cerebellum with the medulla oblongata. 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 27 

The fibres proper of the cerebellum are of two kinds: 
commissural fibres, which cross the middle line to connect 
the opposite halves of the hemispheres, and the arcuate or 
association fibres, which connect one lamina with another. 



WHAT MASSES OF BRAIN MATTER ARE IN THE INTERIOR OF 

THE CEREBEI.I.UM ? 

The nucleus of the roof, or the nucleus fastigii, the 
nucleus emboliformis, the nucleus globosus, and the corpus 
dentatum. The gray matter of the surface with the white 
matter of the interior is so arranged in a series of laminae 
that it gives a foliated appearance which is called the arbor 
vitae. 

HOW IS THE CORTEX OF THE CEREBELLUM DIVIDED? 

Into a granular layer, a layer of large cells, and a molec- 
ular layer. 

The granular layer is composed of minute round cells 
and larger cells with processes called the cells of Purkinje. 

The molecular layer contains large and small cells, some 
of which are multipolar and send processes to end in a plexus 
around the cells of Purkinje. 



WHAT IS THE FUNCTION OFTBE CEREBELLUM? 

The precise function subserved by the cerebellum is not 
exactly known, but there is abundant evidence, experimental 
and pathological, to show that it has to do with coordina- 
tion of movement, and particularly with those muscular 
actions which enable a person to maintain his equilibrium. 
It is the median portion or the vermiform process which is 
really the active portion of the cerebellum and controls 
coordinate movements. Diseases of the outer portions of the 
hemispheres seem to have no effect at all upon the function 
of the cerebellum. 

THE riEDULLA OBLONGATA. 

WHAT IS THE MEDULLA OBLONGATA? 

It is the upper enlarged part of the spinal cord, and ex- 
tends from the upper border of the atlas to the lower border 
of the pons Varolii. It is pyramidal in form, its broad ex- 



28 AT^ ATOMY AND PHYSIOLOGl OF THE NERVOUS SYSTEM 



tremity directed upward, its lower end being narrow at its 
point of connection w^ith the cord. It measures about one 
and one-fourth inches in length and three-fourths of an 
inch in breadth at its widest part, and one-half an inch in 
depth. Its surface has an anterior and posterior-median 
fissure, continuous with the anterior and posterior-median 
fissure of the cord, which divides the medulla into two 



«?--;=" 




Figure 11. 

Anterior view of the mert\illa oblongata, f Sappev). 

1, iufimdibulum. i>, tuber cinereuiu. o. corpora a'lhicantia. 4, cerebral pedun- 
cle. 5, tuber annulare. 6. origin of tlie middle peduncle of tlie cerebellmn. 7. 
anterior pyramids of the medulla oblongata. 8, decussation of tlie anterior 
pyramids. 9, olivary bodies. 10. restiform body. 11, arciform fibers. 12. 
upper extremity of the spinal cord. 13, ligamentum deuticulatum. 14, 11. dura 
mater of the cord. 15. optic tracts. 16. chiasm of the o.ptic nerves. 17, motor 
oculi. 18, patheticus, 19, fifth nerve. 20. motor oculi externus. 21, facial nerve. 
22, auditory nerve. 23, nerve of Wrisberg. 24. glosso-pharyngeal nerve. 2.5. 
pneuraogastric. 2G, 26, spinal accessory. 27, hyi)o-glossal or sul)lingual nerve. 28' 
29, 30, cervical nerves. * 

halves, each half being divided into five columns — the an- 
terior pyramid, lateral tract, olivary body, restiform body 
and the posterior pyramid. There are also arcuate fibres, 
which separate portions of gray matter of the medulla. 
(Fig. 11). 

The posterior surface of the medulla contains part of the 
floor of the fourth ventricle and is 'a most important part 
of the human anatomy, because it contains the nuclei of 
origin of several of the cranial nerves. 



ANATOMY Ais^D i>HYSIOLOGY OF THE NERVOUS SYSTEM. 29 

THE PONS VAROLII. 

WHAT 18 THE PONS VAKOLII AND WHERE IS IT SITUATED ? 

The pons is the bond of union of the various segments of 
the brain, connecting the cerebrum above, the medulla oblon- 
gata below, and the cerebellum behind. It is situated above 
the medulla, below the crura cerebri, and between the hemi- 
spheres of the cerebellum. It is composed of longitudinal 
fibres, which ascend from the medulla to pass to the cere- 
brum, and transverse fibres, which connect the hemispheres 
of the cerebellum. These fibres are arranged in alternate 
layers and are intermixed with gray matter. The transverse 
fibres constitute the great transverse commissure, or tuber 
annulare. The longitudinal fibres are continued up from 
the anterior pyramids, from the olivary body and from the 
lateral and posterior columns of the cord. 



THE VENTRICLES OF THE BRAIN. 

WHAT AKE THE VENTRICLES OF THE BRAIN AND HOW MANY 

ARE THERE? 

They are serous cavities formed in the interior of the 
brain, five in number — two lateral, and the third, fourth 
and fifth. 

DESCRIBE THE LATERAL A ENTRICLES. 

The two lateral ventricles form the upper part of the 
ventricular space. Each consists of a central cavity and 
three smaller cavities or cornua. Each ventricle is lined by 
a thin membrane called the ependyma. They are separated 
from each other by a vertical septum, the septum lucid am. 

The central cavity is bounded above by the corpus cal- 
losum, which forms the roof of the cavity, Its floor is 
formed by the corpus striatum, tenia semicircularis, optic 
thalamus, choroid plexus, corpus fimbriatum and fornix. 

The anterior cornua is triangular in form and curves 
around the anterior extremity of the corpus striatum. It is 
bounded above by the corpus callosum and below and ex- 
ternally by the corpus striatum. 

The posterior cornua curves backward into the substance 
of the posterior lobe. 



30 ANATOMY AND PHYSIOLOGY OF THE NEKYOUS SYSTEM. 
^VHAT IS THE CHOROID PLEXUS? 

It is a little vascular, fringe-like membrane, occupying 
the margin of the fold of pia mater (velum interpositum) in 
the interior of the brain. It extends in a curved direction 
across the floor of the lateral ventricle. 



WHAT IS THE CORPUS FIMBRIATUM OR TENIA HIPPOCAMPI? 

It is a narrow, white, tape-like band situated immedi- 
ately behind the choroid plexus. 



IVHERE IS THE FIFTH VENTRICLE ? 

It is situated between the two layers of the septum luci- 
dum, a semi-transparent septum which is attached above to 
the corpus callosum, and below to the anterior part of the 
fornix. 

DESCRIBE THE THIRD VENTRICLE? 

It is a narrow, oblong fissure situated between the optic 
thalami. It is bounded above by the velum interpositum; 
its floor is formed by the posterior perforated space, corpora 
albicantia, tuber cinereum, infundibulum and the lamina 
cinerea. The cavity of the ventricle is crossed by three 
commissural bands; the posterior connects the optic thala- 
mi; it bounds the ventricle posteriorly and is placed in 
front of and beneath the pineal gland and above the aque- 
duct of Sylvius, a canal leading from the third to the 
fourth ventricle. The middle commissure is composed of 
gray matter and also connects the optic thalami. The an- 
terior commissure is a round, white cord of fibres placed in 
the forepart of the cavity. Just behind the anterior com- 
missure are the foramina of Monro, which afford communi- 
cation between the third ventricle and the two lateral ven- 
tricles by a Y-shaped passage. 



DESCRIBE THE FOURTH VENTRICLE? 

It is the space between the cerebellum and the posterior 
surfaces of the medulla oblongata and pons. It is triangu- 
lar in shape and is roofed over by the valve of Vieussens, a 
thin layer of gray matter, and bounded on either side by 
the superior peduncles of the cerebellum, and behind by the 
diverfirinsr posterior pyramids and restiform bodies. 



M O rOK /V RFA 




Figure 12. 

Diagram illustrating the probable functions of different areas of the cerebral 
cortex. (Ranney). 



PLATE II 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 31 

CEREBRAL LOCALIZATION. 

WHAT IS MEANT BY CEREBRAL LOCALIZATION? 

The determining of the location of the various func- 
tional centres upon the surface of the cerebral cortex which 
control the different parts of the body. (See Plate II). 



NAME CENTRES IN ANTERIOR PORTION OF FRONTAL LOBE. 

Probably the higher mental faculties, such as volition, 
attention, emotion, self-control and thought. 



NAME CENTRES IN POSTERIOR PORTION OF FRONTAL LOBE. 

The head, shoulder^ head and eye movements, and in the 
left third frontal convolution, the speech centre of Broca. 



NAME CENTRES IN ASCENDING FRONTAL AND ASCENDING 
PARIETAL CONVOLUTIONS. 

The trunk, hip, knee, leg, conjoint shoulder, arm^ wrist, 
fingers and thumb, eyes, upper face, lower face, lips, larynx 
and pharynx. 

WHAT CENTRES ARE LOCATED IN THE PARIETAL LOBE ? 

In the superior portion, the foot and toe centre; in the 
middle and inferior convolutions, the areas of sensation, 
touch, pain and temperature. 



WHAT CENTRE IS LOCATED IN THE OCCIPITAL LOBE? 

The centre of sight. 

WHAT CENTRES ARE IN THE TEMPORO-SPHENOIDAL LOBE? 

In the superior portion, the area of hearing; in the in- 
ferior portion, the areas of smell and taste. 



FROM WHENCE DOES THE BRAIN RECEIVE ITS BLOOD SUPPLY ? 

From the two internal carotid arteries, which enter the 
skull through the carotid canals in the temporal bones; and 
from the two vertebral arteries, which after passing through 
the foramen magnum unite to form the basilar artery on 
the surface of the pons Varolii. 

These two vessels give off branches which go to form the 
circle of Willis. 



32 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 
WHAT IS THE CIRCLE OF WILLIS ? 

It consists of two sets of vessels: the anterior or carotid 
set, from which arise the anterior and middle cerebral ar- 
teries; and the posterior or vertebral set, consisting of the 
basilar and posterior cerebral arteries. 

The internal carotid and the posterior cerebral arteries 
are joined together, across the longitudinal fissure, b}^ the 
anterior communicating arteries. 



GIVE ORIGIN AND COURSE OF ANTERIOR CEREBRAL 

ARTERIES. 

The anterior cerebral artery arises from the internal car- 
otid, passes forward in the great longitudinal fissure, 
curves around the anterior border of the corpus callosum, 
running along its upper surface, and anastomoses with the 
posterior cerebral arteries. 



DESCRIBE THE COURSE OF THE MIDDLE CEREBRAL ARTERY. 

The middle cerebral artery is the largest branch of the 
internal carotid. It passes within, the fissure of Sylvius and 
divides into three branches; the anterior supplying the an- 
terior lobe, the posterior supplying the middle lobe, and the 
median supplying the small lobe of the outer extremity of 
the fissure of Sylvius. A particular branch called the lentic- 
ulo-striate artery is distributed to the lenticular and caudate 
nuclei, and is often the source of cerebral hemorrhage. 



GIVE THE COURSE OF THE POSTERIOR CEREBRAL ARTERY. 

The posterior cerebral artery passes along the under sur- 
face of the occipital lobes and gives off branches which pass 
into the posterior perforated space and are distributed to the 
uncinate gyrus, to the temporo- sphenoidal lobe, and the 
cuneus and occipital lobes. 



CRANIAL NERVES. 

GIVE DIVISIONS AND NAMES OF THE CRANIAL NERVES. 

There are twelve pairs. 1st, or olfactory; 2nd, or optic; 
3rd, or motor oculi; 4th, or patheticus or trochlear; 5th, 
or trigeminus or trifacial; 6tli, or abducens; 7th, or fa- 



^ ^he j^eff Fy e y}S^^^Llj^ltl 




Optic and Visual Tracts. N, lesion causing nasal hemianopsia: T, lesion 
lausing temporal hemianopsia; H, lesion causing bi-temporal hemianopsia; C, 
cesion of optic tract, causing left-lateral hemianopsia. 

PLATE III. 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 33 

cial; 8th, or auditory; 9tli, or glosso-pharyngeal; lOth, or 
pneumogastric; lltli, or spinal accessory; 12th, or hypo- 
glossal. 

GIVE THE ORIGIN, COURSE AND DISTRIBUTION OF THE 
CRANIAL NERVES. 

Olfactory. — The first, or olfactory, arises by three 
roots. The outer white root originates in a nucleus of gray 
matter in the anterior part of the middle lobe of the hem- 
isphere, and from the fissure of Sylvius passes along the 
outer side of the anterior perforated space. The middle or 
gray root arises from the anterior perforated space. The inter- 
ior white root arises from the gyrus fornicatus. These roots 
join together to form the olfactory bulb. On their under 
surface they rest upon the cribriform plate of the ethmoid 
bone, and give off about twenty nerves which are distributed 
to the nasal mucous membrane. 

Optic. — The second, or optic, arises from the optic com- 
missure. This commissure is formed by fibres which pass 
across from one side of the brain to the other without any 
connection with the optic nerve, which are called inter- 
cerebral-commissural fibres, and connect the optic thalami 
of the opposite sides. There are also fibres which cross from 
one side to the other in the anterior portion of the commis- 
sure, connecting the optic nerves of the two sides, hav- 
ing no relation with the optic tracts, and called inter- 
retinal-commissural fibres. The fibres of the outer portion 
of each tract pass to the optic nerve of the same side, while 
the central fibres of each tract pass to the optic nerve of the 
opposite side, decussating in the commissure with similar 
fibres of the opposite tract. The optic tracts arise from the 
anterior lobes of the corpora quadrigemina, the corpora gen- 
iculata, and the posterior portions of the optic thalami, 
winding around the crura cerebri. The optic nerve passes 
forward through the optic foramen, enters the back part of 
the eye-ball and expands into the retina. 

Motor Oculi. — The third, or motor oculi, appears in 
front of the pons Varolii, issuing from among the fibres on 
the under side of the crus cerebri. The nerve originates 
from a nucleus beneath the passage-way between the third 
and fourth ventricles, passing forward through the locus 



34 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

niger and the tegmentum, and enters the orbit by the sphe- 
noidal fissure to be distributed to the muscles of the eye- 
ball, with the exception of the external rectus and the su- 
perior oblique. It is the motor nerve of the eye. The fibres 
connected with the internal rectus nucleus decussate. 

Patheticus. — The fourth, or patheticus, or trochlear, 
originates from a gray nucleus in the aqueduct of Sylvius, 
winds around the outer side of the crus cerebri, and enters 
the orbit by the sphenoidal fissure to supply the superior 
oblique muscle. Their fibres decussate in the roof of the 
aqueduct. 

Trifacial. — The fifth, or trigeminus, or trifacial, ap- 
pears at the back of the brain, issuing in two separate 
bundles of fibres from the sides of the pons Varolii near its 
anterior border. Each nerve has two distinct roots; the 
anterior root consisting of three or four bundles of fibres, 
and having motor function; the posterior composed of from 
seventy to one hundred bundles of fibres and having sensory 
function. The two roots commence in the upper portion 
of the medulla, the sensory root originating in the gray 
tubercle of Rolando, and the motor root from some large 
cells connected with the medulla. After the two roots issue 
from the pons they proceed forw^ard to the apex of the 
petrous portion of the temporal bone where a ganglionic 
enlargement occurs upon the sensory root, called the Gas- 
serian ganglion. The motor root passes beneath the gan- 
glion and, not having connection with it, proceeds inde- 
pendently with the inferior maxillary branch of the sensory 
root to the foramen ovale, and after its exit from this fora- 
men blends its fibres with those of the inferior maxillary. 
From the anterior border of the Gasseria^i ganglion three 
nerves are given off; the ophthalmic nerve, which passes 
through the sphenoidal fissure; the superior maxillary nerve, 
which passes through the foramen rotundum; and the in- 
ferior maxillary nerve, which passes through the foramen 
ovale. The ophthalmic branch, which is a sensory nerve, 
supplies the eye-ball, the lachrymal gland, the mucous lin- 
ing of the eye and nasal fossae, the integument and muscles 
of the eye-brow, forehead and nose. The superior maxil- 
lary branch, also sensory, subdivides into branches which 
spread out upon the side of the nose, the lower eye-lid and 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS Sl'STEM. 35 

the upper lip, joining with filaments of the facial nerve. 
The inferior maxillary branch distributes branches to the 
teeth and gums of the lower jaw, the integument, the tym- 
panum and external ear, the lower part of the face and 
lower lip, and the muscles of mastication. It also supplies 
ths tongue with a large branch which possibly serves as a 
nerve of the special sense of taste. The anterior root of the 
fifth nerve, which is motor, divides into two branches which 
supply the muscles of mastication. 

Abducens. — The sixth, or abducens, supplies the ex- 
ternal rectus muscle. It arises from the gray substance in 
the floor of the fourth ventricle, and emerges from between 
the pons and the anterior pyramids of the medulla. It 
leaves the skull by the sphenoidal fissure. 

Facial. — The seventh, or facial, has its deep origin in 
the floor of the fourth ventricle, and emerges between the 
pons and the restiform tract of the medulla. It enters the 
internal auditory opening in the temporal bone, and after 
passing through the aqueduct of Fallopius passes out by 
the stylo-mastoid foramen to be distributed to the facial 
muscles. It is motor in function. 

Auditory. — The eighth, or auditory, also arises from 
the floor of the fourth ventricle, near the origin of the 
seventh nerve and beneath the acoustic tubercles. It enters 
the internal auditory opening of the temporal bone in com- 
pany with the facial nerve. Within the auditory opening 
the nerve subdivides into cochlear and vestibular branches, 
which are distributed to the internal ear. It is the nerve of 
the special sense of hearing. 

Gtlosso-Pharyngeal. — The ninth, or glosso-pharyngeal, 
arises from the floor of the fourth ventricle, below the 
nucleus of the auditory nerve, and appears on the surface of 
the restiform body. It leaves the skull from the middle 
part of the jugular foramen and is distributed to the mucous 
membrane of the pharynx and the back of the tongue. It 
is the special nerve of taste in all parts of the tongue to 
which it is distributed. 

Pneumogastric. — The tenth, or pneumogastric or par 
vagum, is composed of both motor and sensory fibres, and 
supplies the organs of voice and respiration with motor and 
sensory filaments, and the pharynx, esophagus, stomach 



36 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

and heart with motor influence. It has its deep origin in 
the lower part of the floor of the fourth ventricle; and its 
superficial origin between the restiform and olivary bodies, 
below the glosso-pharyngeal, and passes through the jugular 
foramen. 

Spinal Accessory. — The eleventh, or spinal accessory, 
consists of two parts; one, the upper or accessory part to 
the vagus; and the other, the lower or spinal portion. Th^ 
accessory part arises from the medulla, below the pneumo- 
gastric; and the lower part arises from the spinal cord. 
The combined nerve passes out to the jugular foramen with 
the pneumogastric and glosso-pharyngeal nerves; the acces- 
sory portion blends with the pneumogastric, while the spinal 
portion supplies the sterno-mastoid and trapezius muscles. 

Hypoglossal. — The twelfth, or hypoglossal, is the nerve 
of motion of the tongue. It may be seen to arise on the 
surface of the medulla, between the olivary body and 
the anterior pyramid. The nucleus from which it arises is 
found on the floor of the fourth ventricle. It passes out of 
the skull through the anterior condyloid foramen, and is 
distributed to the muscles of the tongue and the depressor 
muscles of the hyoid bone and the^ larynx. 



THE SPINAL CORD. 

WHAT IS THE SPINAL, CORD ? 

It is that portion of the central nervous system con- 
tained within the canal of the vertebral column. In the 
fetus it extends the whole length of the vertebral canal, 
but it does not grow in proportion to the vertebral column 
and in the adult is about fifteen or eighteen inches in 
length. It ends in a mesh of nerve fibres called the cauda 
equina. It is about as large around as a lead-pencil, and is 
in the form of a flattened cylinder with the flat surfaces 
anterio-posterior. It has two enlargements, one called (a) 
the cervical because it is situated in the cervical region; and 
the other, called (b ■ the lumbar enlargement because it is 
situated in the lumbar region. 

(a). The cervical enlargement extends from the third 
cervical to the first dorsal vertebra and its greatest diameter 
is across the cord. 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 37 

(b). The lumbar enlargement extends from the last 
dorsal to the second lumbar vertebra, and its greatest di- 
ameter is antero-posterior. 

The cord weighs about one and one-half ounces when 
denuded of its membranes. 



WHAT ARE THE COVERINGS OF THE CORD ? 

(a) The dura mater, (b) the arachnoid, and (c) the pia 
mater, being of the same structure as and continuous with 
those of the brain. 

(a). The dura mater forms a loose sheath around the 
cord, separated from the walls of the spinal column by 
areolar, adipose tissue. It is attached to the edges of the 
foramen magnum, extends below to the top of the sacrum, 
and then continues as a slender cord to the coccyx, where it 
becomes a part of the periosteum. It is the protecting 
membrane of the cord as it is in the brain. 

(b). The arachnoid is a thin, delicate membrane invest- 
ing the surface of the cord and connected to the pia mater 
by connective tissue filaments. The space between the 
dura mater and the arachnoid is known as the sub-dural 
space. 

(c). The pia mater is beneath the arachnoid membrane 
and invests the cord like a glove. It is the true nourish- 
ing membrane of the cord, and sends prolongations into its 
substance which are abundantly supplied with bloodvessels. 
It sends out also little fibrous processes to the inner surface 
of the dura mater, called the ligamenta denticulatse, situated 
on each side of the spinal cord throughout its entire length 
and separating the anterior and posterior roots of the spinal 
nerves. There are about twenty of these processes upon 
each side of the cord, and they serve as supports to the 
cord. The space between the arachnoid and the dura mater 
is called the sub-arachnoid space. 

Both the sub-dural and the sab-arachnoid spaces are 
filled with cerebro-spinal fluid. This is more abundant, 
however, in the sub-arachnoid space which is directly con- 
tinuous with the ventricular cavities in the interior of the 
brain. The fluid is the same in both and passes from the 
ventricles of the brain through the foramen of Magendie. 
The amount contained within the sub-arachnoid space is 



38 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

probably about an ounce. It acts as a cushion to the spinal 
cord by subduing the effects of shock in the cord from ex- 
ternal violence. The pia mater extends dowuAvard from 
where the cord terminates to the top of the sacral canal in 
a prolongation called the filum terminale. 



WHAT DOES THE SURFACE OF THE SPINAI. CORD PRESENT? 

On its anterior surface, along the median line, there is a 
lono^itudinal fissure called the anterior median fissure; and 
on the posterior surface is the posterior median fissure. 
They divide the cord into two halves which are united in 
the middle throughout their entire length by a band of 
nervous substance called the commissure. The floor of the 
anterior median fissure is formed by white matter called the 
anterior white commissure, and the floor of the posterior 
median fissure is formed by gray matter called the posterior 
gray commissure. 

On either side of the anterior median fissure are the 
anfcero-lateral fissures of the cord, and on either side of the 
posterior median fissure are the postero-lateral fissures. Be- 
tween the postero-lateral fissure and the posterior-median 
fissure are the postero-intermediary fissures. 

The anterior roots of the spinal nerves spring from the 
antero-lateral fissure; the posterior roots of the spinal nerves 
enter the spinal cord at the postero-lateral fissure. 



NAME THE COT.UMNS OF THE CORD. 

On either side of the anterior median fissure are the col- 
umns of Turck, or the direct pyramidal tracts. On either 
side of the columns of Turck are the anterior root-aones. 
Outside of the anterior root-zones are the antero-lateral col- 
umns, or the unknown tracts. The direct cerebellar columns 
occupy the space on either side of the cord at its outer ex-= 
tremity; and just within these columns are the crossed pyr- 
amidal tracts. On either side of the posterior median fissure 
are the columns of Goll, or the posterior-median columns, 
and outside of these columns are the columns of Burdach. 
These latter columns, with the columns of Goll, are often 
called the posterior columns. 

These columns are all composed of white matter. Within 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 



39 



the centre of the cord is the gray substance, and it is so 
arranged as to present on the surface of a section two cres- 
centic masses, one in each lateral half of the cord, united 
by a transverse band of gray matter called the gray com- 
missure. 

Each of these masses has an anterior and posterior horn 
or cornua. The anterior horn is broader and thicker than 




■ Fig-ure 13. 

A diagram showing the more important subdivisions of the spinal cord 

(Flechsig). 

A, anterior median fissure. B, posterior median fissure. C, intermediate fis- 
sure. D, anterior gray cornu. E, posterior gray eornu. V, gray commissure with 
central canal. G, direct pyramidal tract or column of Turck. H, fundamental 
part of the anterior column (anterior root-zones). I. anterior part of lateral col- 
umn. K, crossed pyramidal tract of lateral column. L, direct tract from lateral 
column to cerebellum. M, column of Burdach. N, column of GoU. Cl, vesicular 
column of Clarke. S, sensory tract of lateral column. 



the posterior and does not come to the surface of the cord ; 
while the posterior horn is narrow and projects to the pos- 
tero-lateral fissure upon the surface of the cord. In the 
centre of the gray commissure, and extending throughout 
its whole length, is a small canal called the central canal. 

On the under side of the neck of each posterior cornua, 
just behind the gray commissure, are the visceral columns 
(of Clarke). (Fig. i3). 



40 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 
GIVE THE MINUTE ANATOMY OF THE SPINAI. CORD. 

The gray matter consists of a structure called the sub- 
stantia spongiosa, composed of nerve cells imbedded in a 
mesh of connective tissue, the neuroglia, and is traversed by 
bundles of meduUated nerve fibres passing in different direc- 
tions and interspersed with small bloodvessels. The cells 
of the anterior cornua are large and multipolar. The pro- 
cesses of these cells intermingle with each other. Many of 
the medullated nerve fibres are connected by their axis- 
cylinders with the nerve cells, then become associated into 
bundles, which go to form the anterior roots of the spinal 
nerves. Transverse nerve fibres passing through the an- 
terior commissure connect some nerve cells of the opposite 
side with each other. The gray commissure consists chiefly 
of transverse medullated fibres upon a matrix of neuroglia. 
Some of these fibres pass from the posterior roots of the 
spinal nerves of one side across the gray commissure to the 
posterior cornua of the opposite side; some pass to the 
anterior cornua of the same side, and some to the anterior 
cornua of the opposite side. 

The white matter is destitute of nerve cells, and is com- 
posed of longitudinal medullated lierve fibres, except in the 
white commissure, where the fibres are transverse, and in 
the anterior roots of the spinal nerves, where they are 
oblique. The white commissure is formed of fibres extend- 
ing from the anterior cornua of gray matter on one side to 
the white substance of the anterior column of the opposite 
side. The nerve fibres of the white matter are supported by 
neuroglia which has small bloodvessels ramifying within it. 

The nerve fibres within the spinal cord are destitute of 
the white sheath of Schwann. The coarser fibres are found 
in the white matter, the next in size are found in the an- 
terior gray matter, while the finest nerve fibres are found in 
the posterior gray matter. 



WHAT IS MEANT BY A SEGMENT OF THE SPINAL CORD? 

A segment of the spinal cord is a transverse section 
about the wddth of one of the vertebrae, including a pair of 
spinal nerves. The spinal cord is composed of a series of 
superimposed segments. 




PLATE IV. 

Sensory Tract, a, h, cells of 
spinal ganglia, one fibre, p. 
forming part of sensory nerve, 
the other fihre, c, entering a 
posterior root, fibres of the 
latter dividing into ascending 
and descending (l, 2, 3, 4) 
branches; of the ascending 
branches some (4) terminate 
with "end-brushes" in the nu- 
cleus cuneatus, and nucleus 
gracilis; col, collateral fibres 
entering gray matter; 8, fibres 
forming anterior ground bun- 
dle; 5, 6, fibres forming lateral 
ground bundle; 10, fibres form- 
ing Gowers's tract; 7, fibres 
forming direct cerebellar tract. 
(After Flateau.) 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 41 
WHY ARE THE DIRECT PYRAMIDAL TRACTS SO CALLED ? 

Because they convey longitudinal fibres directly from 
the anterior pyramids within the medulla down to the spinal 
cord. 

WHY ARE THE CROSSED PYRAMIDAL TRACTS SO CALLED ? 

Because their fibres decussate within the medulla. Nine 
fibres decussate to one that passes directly down. 



WHAT ARE THE FUNCTIONS OF THE DIRECT AND CROSSED 
PYRAMIDAL TRACTS? 

They convey motor impulses from the brain to the peri- 
phery. 

WHAT ARE THE FUNCTIONS OF THE COLUMNS OF GOLL AND 

BURDACH ? 

The columns of Goll convey sensory impulses, probably 
tactile sense. 

The columns of Burdach convey tactile sense; they also 
convey sensations from the muscles and articulations, and 
when they are diseased there is a loss of the so-called muscu- 
lar sense. 

The fibres of the columns of Goll decussate in the me- 
dulla, while those of the columns of Burdach cross over at 
once. 

WHAT ARE THE FUNCTIONS OF THE ANTERO-LATERAL 

COLUMNS ? 

The antero-lateral columns convey sensations of pain and 
temperature from the opposite side of the body, coming 
across the anterior and posterior commissures. 

WHAT ARE THE FUNCTIONS OF THE CELLS CONTAINED IN THE 

GRAY MATTER? 

The cells in the anterior horn have motor and trophic 
functions. The larger cells are situated at the outer part of 
the horn and send fibres to the large muscles. The smaller 
cells are situated near the centre and send fibres to the small 
muscles, those having more delicate function. In the inner- 
most cells are the trophic cells for muscles and groups of 
cells which preside over vaso-motor and secretory functions. 



42 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

The visceral columns of Clarke receive fibres from the vis- 
cera and bloodvessels, and conduct impulses from the vis- 
cera. 

The cells of the posterior horns are sensory in function. 
In the posterior horns there are also situated the trophic 
centres for the joints, bones and skin; their fibres pass out 
through the posterior roots. 



WHAT IS MEANT BY THE AUTOMATIC ACTION OF THE SPINAIi 

CORD ? 

That function of the spinal cord which enables it to per- 
form voluntary actions independently of the brain, as when 
a person suddenly recovers himself after slipping upon some 
substance. There are groups of nerves and cells in the cord 
which are called spinal automatic centres. They are: 

(a). The cilio-spinal centre, which extends from the 
seventh cervical to the second dorsal vertebra; and its 
stimulation causes the pupil to contract. 

(b). The genital centres which extend from the first to 
the third sacral segments and preside over erection and 
ejaculation. 

(c). The bladder and rectal centres, which are located in 
the fifth sacral segment. 

(d). The vaso-motor centres, located in that portion of 
the cord extending from the second dorsal to the second 
lumbar segments. 

GIVE THE BLOOD SUPPLY OF THE SPINAL CORD. 

From the branches of the vertebral, ascending cervical 
and superior intercostal arteries above, and from the dorsal, 
intercostal, lumbar and sacral arteries below. They enter 
the spinal cord through the foramen magnum above and 
the intervertebral foramina on the sides. They are dis- 
tributed on the pia mater and in the cord. 

The arteries that thus supply the cord are the anterior 
spinal, posterior spinal and lateral spinal. 

The anterior spinal arteries unite to form the anterior 
median artery which extends down the whole length of the 
cord, receiving branches from the lateral arteries. 

The posterior spinal arteries are much smaller than the 
anterior, and unite with each other on the posterior surfaces 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 43 

of the cord. They do not continue down, however, in the 
median artery as the anterior arteries do. 

The lateral spinal arteries are derived from branches of 
the subclavian. 

The substance of the cord is supplied by central arteries 
which are branches of the anterior median and peripheral 
arteries, coming from plexuses on the pia mater. 

SPINAL NERVES. 

WHAT ARE THE SPINAL NERVES ? 

Nerves which take their origin from the spinal cord and 
pass through the intervertebral foramina on each side of 
the spinal canal. They are arranged in groups correspond- 
ing with that portion of the spinal canal through which 
they pass. There are thirty-one pairs of them — the cervi- 
cal, having eight pairs; dorsal, twelve pairs; lumbar, five 
pairs; sacral, five pairs and the coccygeal one pair. Each 
pair arises from two roots; an anterior or motor root and a 
posterior or sensory root. Upon the posterior root is the 
small ganglion which is common to all sensory nerves. The 
two roots join together to form a combined nerve which 
passes out of the spinal cord. 



WHAT ARE THE DIVISIONS OF THE SPINAI. NERVES? 

After the spinal nerves pass out of the intervertebral 
foramina they divide into an anterior division, which sup- 
plies the anterior part of the body, and the posterior division, 
which supplies the posterior part. Each of these divisions 
contains fibres from both roots. 

The anterior divisions are usually larger than the pos- 
terior, because they supply a larger extent of structure. 
Each division is connected with the sympathetic by a slender 
filament. 



WHAT PLEXUSES DO THE ANTERIOR DIVISIONS OF THE 
SPINAL NERVES FORM? 

The four upper cervical nerves form the cervical plexuses; 
the four lower cervical nerves and first dorsal form the 
brachial plexus; and the anterior divisions of the dorsal 
from the second to the eleventh constitute the intercostal 



44 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

nerves; the four upper lumbar nerves form the lumbar 
plexuses; and the five lumbar nerves and four upper sacral 
nerves form the sacral plexus. 



WHAT DO THE POSTERIOR DIVISIONS SUPPLY ? 

The erecto-spinse muscles and the superficial muscles of 
the back; also the skin of the back of the head, neck and 
trunk. 

INTO WHAT TWO GROUPS ARE THE BRANCHES OF THE CER- 
VICAL, PLEXUS DIVIDED? 

Into the superficial and deep. 

Superficial Group. — Branches of the superficial group 
are the superficialis-colli, the auricularis magnus and the oc- 
cipitalis minor, the sterno-clavicular and acromial. 

Deep Group. — The branches of the deep group are the 
communicating, muscular, communicans noni and the phreni. 



WHAT ARE THE BRANCHES OF THE BRACHIAL PLEXUS? 

They are divided into tvvo groups — those above the clavi- 
cle and those below. 

The branches above are the communicating, muscular, 
posterior thoracic and supra-scapular. 

The branches below the clavicle are the anterior thoracic, 
distributed to the chest; the subscapular and circumfiex, 
distributed to the shoulder; the musculo-cutaneous, inter- 
nal cutaneous, lesser cutaneous, median, ulnar and mus- 
culo-spiral, distributed to the arm, forearm and hand. 



HOW^ MANY INTERCOSTAL NERVES ARE THERE AND TO WHAT 
ARE THEY DISTRIBUTED ? 

Twelve on each side, distributed to the parietes of the 
chest and abdomen. They are not joined together in a 
plexus, in which respect they differ from the other spinal 
nerves. 

The six upper nerves are distributed to the walls of the 
chest; and the six lower supply the walls of the chest and 
the abdomen. 



ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 45 

TO WHAT ARE THE POSTERIOR DIVISIONS OF THE DORSAI. 
NERVES DISTRIBUTED? 

They are divided into external and internal branches. 

The external branches are distributed to the longissi- 
mus dorsi, the sacro-lumbalis and the levatores costarum. 

The internal branches supply the multifidus spinse, the 
semi-spinalis dorsi, the rhomboidei and the trapezius. 



WHAT DO THE POSTERIOR DIVISIONS OF THE LUMBAR 

NERVES SUPPLY? 

The erector spinse and inter-transverse muscles, the 
latissimus dorsi, the integument of the gluteal region, and 
some of its fibres pass as far as the trochanter major. Some 
of its branches supply also the multifidus spinae and inter- 
spinalis muscles. 

WHAT DO THE ANTERIOR DIVISIONS OF THE LUMBAR 
NERVES SUPPLY? 

The lumbar plexus, which gives off the following 
branches: the ilio-hypogastric, ilio-inguinal, genito-crural, 
external cutaneous, obturator, accessory obturator, anterior 
crural; they also supply the integument of the front and 
under side of the leg and all the muscles of the front of the 
thigh except the tensor vaginae femoris. 



HOW ARE THE SACRAL NERVES DIVIDED AND WHAT ARE 
THEIR BRANCHES? 

The first four are divided into anterior and posterior 
branches 

The posterior branches pass through the posterior sacral 
foramina and supply the multifidus spinse muscles and the 
integument, the sacrum and coccyx. 



WHAT CONSTITUTES THE SACRAL PLEXUS? 

The first three anterior branches, with the lumbo-sacral, 
and the four sacral nerves which unite and form the sacral 
plexus. A large number of the fibres of this plexus go to 
form the sciatic nerve. The sacral and coccygeal nerves 
arise from the caada equina. 

The following are the branches of the sacral plexus: 
Superior gluteal, muscular, pudic, small sciatic, great sci- 



46 ANATOMY AND PHYSIOLOGY OF THE NERVOUS SYSTEM. 

atic. These nerves are the ones that have the most to do 
'vith the function of standing and moving. They control 
the lower extremities entirely and also the posterior mus- 
cles of the thigh and buttocks. Some of their fibres regu- 
late the functions of the sexual organs, the bladder and the 
rectum. 



PART II. 

SYMPTOMATOLOGY. 



ORGANIC AND FUNCTIONAL DISEASE=SYMPTOnS. 

INTO WHAT TWO GREAT CLASSES ARE NERVOUS DISEASES 

DIVIDED ? 

Organic and functional. Organic when the disease is 
accompanied by structural change in an organ. Functional 
when only the action of an organ is disturbed. 



INTO WHAT TTVO CLASSES ARE SYMPTOMS DIVIDED ? 

Objective — those recognizable by another person— and 
subjective — those discerned only by the patient. 



HOW MANY KINDS OF FUNCTIONAL NERVE-DISEASE SYMP- 
TOMS ARE THERE? 



Three: Motor, sensory, and trophic. 



WHAT MOTOR SYMPTOMS ARE OBSERVED ? 

Paralysis. — Loss of motion of a part. 

Paresis. — Weakness of a part. 

Hemiplegia.— Loss of power of one-half of the body. 

Paraplegia. — Loss of power of the lower half of the 
body. 

Monoplegia. — Loss of power of one extremity. 

Hemi-Paraplegia. — Loss of power of one of the lower 
extremities. 

Diplegia. — Paralysis of corresponding muscles on the 
two sides of the body. 

Tremor. — A more or less continuous quivering of a con- 
vulsive character. It may occur during rest and cease upon 



48 SYMPTOMATOLOGY. 

volmntary motion; or it may occur only upon voluntary 
motion, when it is called intention tremor. 

Fibrillary Tremor. — Convulsive action of individual fibres 
of a muscle, occurring during the progress of some wasting 
disease affecting the muscle. 

Convulsion. — A more or less violent muscular contrac- 
tion of voluntary muscles in general. It may be tonic, a 
condition of continuous contraction; or clonic, a condition 
of irregularly occurring violent contraction and relaxation. 

Spasm. — A term more commonly applied to a convulsive 
contraction of the muscles of a particular portion of the 
body. 

Choreic Movements. — A sudden jerking or twitching of 
groups of muscles and not controllable by the will. 

Convulsive Tic. — Choreic movements of certain groups 
of muscles, which work together for a common purpose, 
such as muscles of the face, eyes and larynx. 

Athetosis. — A successive slow extension, flexion, prona- 
tion and supination of the fingers hand and arm, or of the 
toes and feet. 

Rigidity. — Tonic contraction of muscles. 

Contracture. — A permanent contraction of a muscle with 
rigidity which often produces permanent deformities of a 
joint, the various forms of talipes being conditions of this 
kind. 

IncO'Or dictation — An inability to properly control mus- 
cular contraction by which motion is produced, thus pre- 
venting exact movement of a part. 



WHAT SENSORY SYMPTOMS MAY OCCUR? 

Anesthesia. — Loss of the power of sensation in a part. 

Analgesia. — Loss of sensation to pain; may feel pressure 
from the prick of a pin, but not pain, 

Thermo-Anesthesia, — Loss of sensation to heat. 

Ataxia, — Loss of the power of co-ordination due to mus- 
cular anesthesia, or loss of the muscular sense. 

Static Ataxia. — Inability to preserve the equilibrium 
when standing. 

Motor Ataxia. — Inability to co-ordinate the limbs in mo= 
tion. 



SYMPTOMATOLOGY. 49 

Cerebellar Ataxia. — Inco-ordination due to disease of the 
cere bell am. 

Hyperesthesia, — Over-sensitiveness to external impres- 
sions. 

Hyperalgesia. — Over-sensitiveness to pain. 

Paresthesia. — Any abnormal sensation except pain; as 
numbness, tingling, formication, etc. 

Delayed Sensation. — In which a longer than normal time 
intervenes between the stimulation of a part and the per- 
ception of the stimulation. 



WHAT JS MEANT BY TROPHIC SYMPTOMS ? 

Those symptoms which pertain to the nourishment of a 
part. 

WHAT TROPHIC DISTURBANCES MAY BE OBSERVED? 

Atrophy. — Wasting of a part due to lack of nourish- 
ment. 

Hypertrophy. — Increased size of a part due to excess of 
nourishment. 

Dystrophy. — Defective nutrition. 

Anthropathies. -Diseases. of the joints due to some gen- 
eral nervous condition. 

Angio-Neurosis. — Disease of vaso-motor nerves affecting 
the blood supply of a part. 

Angiospasm. — Irritation of the vaso-motor centers pro- 
ducing contraction of the vessels. 

Angio-Paralysis. — Loss of power of vaso-motor nerves, 
allowing dilatation of the vessels. 



WHAT IS MEANT BY REFLEX ACTION? 

When an impulse travels up a sensory nerve to the 
spinal cord and is there transformed to a motor impulse and 
conveyed along a motor nerve to another part, it is called 
reflex action. 

HOW^ DO WE DENOMINATE THAT PART OF THE SPINAL CORD 
WITH THE SENSORY AND MOTOR NERVE ROOTS WHERE THE 
CHANGE FROM SENSORY TO MOTOR IMPULSE TAKES PLACE? 

The motor-sensory arc. 



50 SYMPTOMATOLOGY. 

HOW MANY KINDS OF REFLEXES ARE THERE AND WHAT 

ARE THEY? 

Four. (a). Superficial or skin reflexes, such as the plantar, 
the gluteal, the ceremaster, the abdominal, the epigastric 
and the scapular reflexes. 

(b). Deep or tendon reflexes, obtained by striking a ten- 
don that has been already put upon the stretch. The most 
common is the patella reflex, producing the so-called knee- 
jerk, the sudden kicking outward of the leg, the foot clonus, 
the peroneal and the tendo Achillis reflexes. 

(c). Visceral reflexes, produced by the irritation of one 
disordered viscus upon another. 

(d). Idiopathic muscle reflexes, occurring independently 
in muscles when struck with a blunt instrument, and pre- 
senting a welt of contracted muscle lasting several seconds. 



HOW MAY REFLEX ACTION BE AFFECTED BY NERVOUS 

DISEASES ? 

It may be lost, when the reflex arc is interrupted, or it 
may be exaggerated. 

WHAT IS MEANT BY ELECTRICAL, IRRITABILITY? 

The property which muscles and nerves possess of re- 
sponding to electrical irritation. 



HOW MAY ELECTRICAL IRRITABILITY BE AFFECTED BY' 

DISEASE ? 

It may be lost or increased, or the normal electrical for- 
mula may be changed. 

DIGESTIVE TRACT SVnPTOnS. 

WHAT SYMPTOMS ARISE FROM DISTURBANCES OF THE DIGES- 
TIVE ORGANS? 

Anorexia. — Loss of appetite, common in febrile condi- 
tions and various disturbances. 

Bulimia. — An inordmate craving of food, often a symp- 
tom of hysteria and epilepsy. 

Vomiting. — A most frequent and important symptom of 
intracranial diseases, such as meningitis, tumor, a<bscess, 
hemorrhage, increased intra-cranial pressure, toxemic con- 



SYMPTOMATOLOGY. 51 

ditions acting upon the medulla, and hysteria. While it 
may occur from disease in any part of the brain, it is most 
common in diseases of the cerebellum. It often occurs 
early, may be produced by diseases of slight extent, and is 
ascribed to an increased inability of the gastric part of the 
pneumogastric centre. The vomiting usually occurs soon 
after food is taken in cerebral diseases. There may be no 
gastric distress whatever. The vomiting may be unattended 
by nausea, or the nausea may be most distressing. The cer- 
ebral condition which produces vomiting will usually cause 
headache; and the co-existence of persistent pain in the head, 
with frequent vomiting, should make us suspicious of cere- 
bral disease. There may also be present an optic neuritis 
with these symptoms. Projectile vomiting, forcible ejection 
of food from the stomach, with nausea, occurs in meningitis 
and almost all organic diseases of the brain. 

Constipation. — Frequently a symptom of tumor, menin- 
gitis, apoplexy and cerebral softening. It is also an import- 
ant and persistent symptom of diseases of the spinal cord 
above the lumbar enlargement. 

Incontinence of Feces. — May be due to diseases of the cen- 
tre that controls the sphincter ani muscles, or perhaps of the 
pyramidal tracts. 

URINARY SYMPTOMS. 

WHAT URINARY SYMPTOMS ARE OBSERVED ? 

Incontinence of Urine. — Due to disease of the spinal cord, 
particularly in that part which controls the sphincter of the 
bladder. In myelitis, the last stages of locomotor ataxia, 
cerebral hemorrhage, cerebral embolism and cerebral soften- 
ing it is a common symptom. 

Inability to Void Urine. — Occurs in the first stages of 
locomotor ataxia and in conditions of lowered cerebral func- 
tion from whatever cause. 

Overflow-Incontinence. — In which the bladder is never 
fully evacuated of the urine, which runs off as soon as it 
reaches the level of the urethral orifice, is due to a paralysis 
of the walls of the bladder, and is a symptom of disease of 
the spinal cord affecting the lumbar region, and also to cere- 
bral innervation. Urine and feces may both be passed in 



6^ SYMPTOMATOLOGY. 

bed in cases of mental impairment without any actual loss 
of power of the sphincters. 

WHAT CHANGES OCCUR IN THE CONSTITUENTS OF THE URINE 7 

It is excessively acid when overflow-incontinence is 
present. The quantity of urea is reduced in such functional 
disturbances as epilepsy, headache and hysteria. Albumin- 
uria may occur after excessive mental or physical exertion, 
in hemorrhage of the brain, digestive or neurotic dis- 
turbances, and after convulsions due to functional or organic 
disease of the brain. Earthy phosphates are in excess in all 
forms of nervous disease where there is great expenditure of 
nerve force. 

SEXUAL SYMPTOnS. 

WHAT SYMPTOMS ARISE IN THE SEXUAL ORGANS ? 

Nymphomania. — Excessive sexual desire in women. 

Satyriasis. — Excessive sexual desire in men; may occur 
in organic diseases of the brain, in insanity, hysteria, epi- 
lepsy and the first stages of locomotor-ataxia, and from any 
disease of the spinal cord affecting the sexual centre. 

Impotence. — Inability to perform the sexual act; may be 
platonic, resulting from the abolition of the power of 
erection, due to organic disease of the spinal cord or brain; 
or may be psychical, due to a lack of self-confidence, fear, 
shame or the like. Careful examination should be made to 
determine the position of the uterus and its general condi- 
tion, as many reflex symptoms observed in other parts of the 
body are due to mal-position or disease of this organ. 



EYE SYMPTOMS. 

WHAT ABNORMAL CONDITIONS ARE SEEN IN THE EYE? 

(a) Hemianopsia, (b) diplopia, (c) asthenopia, (d) am- 
blyopia, (e) achromatopsia, (f) amaurosis and (g) pupillary 
reflexes. 

WHAT IS HEMIANOPSIA ? 

Blindness in one-half of the eye; it may be bilateral or 
homonomous. Bilateral may be either bi-nasal or bi-tem- 



SYMPTOMATOLOGY. 53 

poral. Homonomous is that condition in which the nasal 
half of one eye and the temporal half of the other eye are 
blind. 

In homonomous hemianopsia the lesion is posterior to 
the chiasm, either in the optic tract, the thalamus, the cor- 
tex of the occipital lobe or fibres that connect it with the 
optic tract. 

In bi-nasal hemianopsia the lesion occurs at the chiasm. 

Bi-temporal hemianopsia is extremely rare, but may 
occur as the result of atheromatous degeneration of the 
circle of Willis, which impairs the elasticity of the arteries, 
these producing, by their continuous pulsations, a slight 
injury to the chiasm, affecting only the fibres distributed to 
the temporal halves of the eye. 



WHAT IS DIPI.OPIA AND HOW IS IT PRODUCED ? 

Double vision — produced by paralysis or spasm of one of 
the muscles of the eye, such as sometimes occurs in squint. 
It may occur as the result of meningitis, cerebral tumor or 
almost any organic change in the brain. 



WHAT IS ASTHENOPIA? 



Weak sight — a symptom of general nervous weakness, 
such as occurs in hysteria and neurasthenia. 



WHAT IS AMBLYOPIA AND WHAT CAUSES IT ? 

Dimness of vision — it may be organic, due to lesion of 
the peripheral visual nervous system, or to diseases of both 
hemispheres of the brain. Toxemic amblyopia is usually of 
organic origin, but the lesion is directly produced by poison- 
ing, and may be recovered from by the removal of the poison 
from the system. Tobacco, lead, quinine and santonine maj 
produce this condition. 



WHAT IS ACHROMATOPSIA? 



Color-blindness — is a common symptom of hysteria, but 
is most frequently congenital. 



54 SYMPTOMATOLOGY. 

WHAT IS AMAUROSIS? 

Total loss of vision, without any change in the optic 
nerve — is often a symptom of hysteria or may be due to dis- 
ease of the cerebellum. 



WHAT PUPILLARY REFLEXES ARE OBSERVED ? 

Rigidity of the pupils occurs in sclerosis of the cilio-spinal 
axis in locomotor ataxia. In the Argyle-Robertson pupil 
there is no accommodation to light, but there is accommo- 
dation for distance; that is when light is brought to bear 
upon the pupil it does not contract; but it does contract 
and dilate to the varying distance of an object. This con- 
dition is also found in locomotor ataxia. Immobility of the 
pupil may also be found in hysterical conditions and in 
some forms of insanity. 

WHAT DO WE DETERMINE BY AN OPTHALMOSCOPIC EXAMI- 
NATION ? 

The condition of the fundus and the optic nerve. There 
may be a neuro-retinitis, an inflammation of the optic nerve 
and retina, often called "choked disk," which is a common 
symptom in cerebral tumor, meningitis and cerebral abscess. 
It sometimes occurs as the result of embolism of the central 
artery, associated with embolism of a cerebral artery. It 
may also result from other causes than intra-cranial dis- 
ease, such as albuminuria, chlorosis, lead poisoning and 
anemia. 

Atrophy of the optic nerve may be the result of a neuri- 
tis or of uncomplicated intra-cranial disease. 



EAR SYMPTOnS. 

WHAT DEFECTS OF HEARING ARE THERE ? 

There may be deafness, due to some disease of the mid- 
dle ear, or to disease of the brain or auditory nerve. The 
nerve may be pressed upon by syphilitic, tubercular, or 
other exudations at the base of the brain, and is exposed to 
paralysis from disease of the mastoid process of the tem- 
poral bone. If there be deafness without giddiness it is 
usually due to a lesion of the nerve trunk. The nuclei of 
the eighth nerve within the pons may be destroyed by 



SYMPTOMATOLOGY. 55 

hemorrhage, softening or tumor, producing deafness. Loss 
of hearing may sometimes occur in hysteria, and in anemia 
for want of blood. 

HOW DO WE DISTINGUISH BETWEEN DEAFNESS THAT IS PRO- 
DUCED BY A NERVE LESION AND THAT DUE TO A CATAR- 
RHAL TROUBLE? 

(a). In deafness due to a catarrhal disease if the 
vibrating tuning-fork be held near the ear it may not be 
heard; but if the handle of the tuning-fork be placed in 
contact with the bones of the skull the vibrations may be 
heard — showing that bone conduction is good while aerial 
conduction is poor. 

(b). In deafness due to nerve disease the vibrations 
cannot be heard either through the bone or the ear. 



WHAT OTHER DEFECTS OF HEARING ARE THERE ? 

(a). Hyperesthesia of hearing, in which the sense of 
hearing is largely increased, may occur in hysteria. 

(b). Auditory dysesthesia, in which the sounds, though 
not heard with undue loudness, cause discomfort — is com- 
mon in brain diseases, functional and organic, and during 
cases of headache, meningitis, etc. 

(c). Tinnitus aurium, a subjective sound, varying in 
character and intensity — heard by patients suffering from 
nervous exhaustion, anemia, shock, and during great men- 
tal strain; may also be produced by various forms of ear 
disease, and also by the administration of large doses of 
quinine. 

(d). Aural vertigo, or Meniere's disease, in which there 
is sudden and extreme dizziness, often causing the patient 
to fall, with intense pain in the ear, and due to some dis- 
ease of the labyrinth. 



NASAL SYMPTOMS. 

WHAT ABNORMALITIES OF THE SENSE OF SMELL ARE 

OBSERVED? 

(a). Anosmia, loss of the sense of smell, is usually due 
to some disease of the mucous membrane of the nose, but 
may be caused by disease affecting the olfactory bulb or 



56 SYMPTOMATOLOGY. 

nerve, due to compression or inflammation in cases of tumor 
in the anterior fossa of the skull, in caries of the bone, men- 
ingitis, syphilis, etc. 

(b). Hyperosmia, or hyperesthesia of the sense of smell, 
occurs in hysteria, and hallucinations of the sense of smell 
occur in insanity. 

GUSTATORY SYMPTOMS. 

WHAT PECULIARITIES OF TASTE ARE FOUND? 

(a). Parageusia, perversion of the sense of taste, occurs 
in hysteria, insanity, and in influenza apart from the 
catarrh; also in tabies dorsalis. 

( b ) . Hypergeusia, increased sensitiveness of the sense of 
taste, is common in hysteria. 

(c). Loss of the sense of taste may be due to paralysis 
of the lingual branch of the fifth nerve and also the glosso- 
pharyngeal, the first supplying the anterior portion of the 
tongue and the latter the posterior. 



SYflPTOMS PERTAINING TO SPEECH. 

WHAT DEFECTS OF SPEECH OCCUR? 

(a). Aphasis, an inability to articulate words, without 
any impairment of the nerves and muscles used in speaking. 
There are two general divisions of aphasia: motor or ataxic 
aphasia, and sensory or amnesic aphasia. 

1. Motor aphasia is due to a lesion in the speech centre 
of Broca, situated in the posterior portion of the left third 
frontal convolution of the brain. 

2. Amnesic aphasia is divided into four kinds: (i). 
Paraphasia, substitution of wrong words or symbols occur- 
ring in conversation or during writing, due to a lesion 
in the Island of Reil; or a lesion interferes with the action 
of the associating tracts of fibres between the areas of hear- 
ing or sight and the motor speech centre of Broca. (ii). 
Agraphia, loss of the power of writing, due to the loss of 
certain memories which previously enabled the person to 
write, (iii). Word-deafness, an inability to understand 
spoken language, due to a lesion of the first temporal con- 
volution, (iv). Word-blindness, an inability to understand 



SYMPTOMATOLOGY. 57 

the meaning of printed or written symbols, and occurring 
in lesions of the visual centre in the occipital lobes. 
Aphasia may sometimes be associated with: 

1. Alexia, an inability to read. 

2. Amimia, an inability to express one's self more by 
gestures. 

3. Apraxia, inability to recognize objects in common 
use. 

4. Aphemia, an inability to express what is the matter 
with one's self. 

5. Asymbolia, inability to sign the name. 

6. Paraphasia, misplacing words in speaking. 

7. Anarthria, stammering, an inability to pronounce 
letters properly, due to a difficulty in moving the tongue, 
owing to paralysis of the hypoglossus, produced by a lesion 
of the medulla which interferes with the function of the 
nuclei of the cranial nerves associated with speech. 

Any lesion affecting the speech tract in the internal cap- 
sule may also produce an inability of speech. 



METHOD OF INSPECTION. 



INSPECTION. 

WHAT IS THE FIRST METHOD TO BE EMPLOYED IN THE EX- 
AMINATION OF A NEUROLOGICAL CASE? 



Inspection. 



WHAT IS MEANT BY INSPECTION ? 

The act of viewing critically objective signs. 



TYHAT ARE THE POINTS TO BE NOTED BY THIS METHOD ? 

The features and general appearance of the patient; the 
position, whether lying, sitting, standing or walking; 
whether conscious or unconscious; quiet or restless; silent 
or speaking; the general nutrition; deformities; the mental 
condition; and all other objective symptoms that may be 
present. 



58 METHOD OF INSPECTION. 

WHAT WILL BE LEARNED BY AN EXAMINATION OF THE FEA- 
TURES ? 

To one versed in physiognomy the temperament will be 
revealed. 

WHAT IS MEANT BY THE TEMPERAMENT ? 

The peculiar mental and physical character of an indi- 
vidual. 

HOW MANY TEMPERAMENTS ARE THERE, AND WHAT ARE 

THEY CALLED ? 

Four. (a). The lymphatic, depending upon the predomi- 
nance of the digestive system, characterized by roundness 
of form, repletion of cellular tissue, softness of flesh, a weak 
pulse and a languid condition of the system generally. The 
complexion is pale, the hair generally light in color, and the 
eyes light and dull. Persons with this temperament bear 
pain and illness poorly and do not recuperate well. 

(b.) The sanguine, depending upon the predominating 
influence of the arterial system, indicated by a moderate 
plumpness of parts, tolerably firm muscles, light or chestnut 
hair, blue eyes, a strong, full face, and an animated counte- 
nance. Persons with this temperament are lively and im- 
pressible, and possess more activity and energy than those 
having the lymphatic temperament. 

(c.) The bilious temperament, having the liver for a 
basis, has for its external signs black hair, dark, yellowish 
skin, black eyes, firm muscles and harshly expressed form. 
It indicates activity, energy and power. 

(d). The nervous temperament is marked by light, thin 
hair, sleriderness of form, delicate health, general emacia- 
tion, rapidity of muscular action. It imparts great sensi- 
bility and mental activity. Persons having this temperament 
may become ill quickly and recuperate as quickly. 

There are also what are called mixed temperaments, in 
which there are two temperaments combined, such as nervo- 
bilious or nervo-sanguinous, the one named first usually 
predominating. 

WHAT IS TO BE LEARNED BY AN EXAMINATION OF THE HEAD 

AND FACE. 

The well developed forehead will denote intellectuality. 
If it be protuberant and over-hanging a small undeveloped 



METHOD OF INSPECTION. 59 

face, it is likely that rickets, hereditary syphilis or hydro- 
cephalus has existed. 

A narrow, retreating forehead denotes lack of the higher 
mental faculties. 

The face will show the complexion, whether it be natu- 
ral as in health, or pale and sallow. 

A pale face would denote either a transient fainting or a 
general anemic condition consequent upon ill-health. 

A red face might be due to a paresis of the vaso-motor 
nerves supplying the vessels as the result of a lowered nerve 
tone of the general system, or to cerebral congestion. 

A bluish-red face would indicate venous congestion, due 
probably to some heart trouble. 

A light, yellowish color may indicate cancer in some part 
of the body; deep yellow, jaundice; a waxy, transparent 
face, Bright's disease. 

The face will also indicate the general feeling of the 
patient, whether in pain or not, and whether there be any 
mental anxiety or not. Bulbar paralysis is at once de- 
termined by inspecting the face. Bell's palsy, paralysis of 
the seventh nerve, is likewise observed. Spasm of the mus- 
cles due to convulsive tic may also be seen. Eruptions upon 
the face occur in some forms of neuritis. Swelling of one 
or both sides of the face may result from neuralgia, inflam- 
mation, or angio-neurotic edema. 



WHAT MAY BE OBSERVED ABOUT THE EYELIDS? 

Whether they be open, as they should be, or drooping. 
A drooping upper lid, that can be raised when the patient so 
wishes, denotes languor due either to laziness or exhaustion. 
A drooping upper lid that cannot be raised is called ptosis, 
and indicates a paralysis of the third cranial nerve. In par- 
alysis of the facial nerve the eyelid of the affected side can- 
not be closed. Eyes extremely wide open indicate either 
astonishment, fright or exophthalmus. Twitching of the 
eyelids may be due to nervous exhaustion^ chorea, to spinal 
irritation, or convulsive tic. 



WHAT IS TO BE DETERMINED FROM THE EYE ? 

Whether it be large and protruding (exophthalmus), as 
in Basedow's disease, in orbital tumor, or edema of the 



60 METHOD OF INSPECTION. 

orbit; or if it be sunken, as in the last hours of life, or from 
evacuation of its humors. Whether it be bright as in 
health, or over-bright, as from mental stimulation; or if it 
be dull, as in paralysis of the orbicularis palpebrarum, in 
melancholia, or in approaching dissolution. Whether fixed 
and staring, as during a convulsion (of epilepsy or cata- 
lepsy), or oscillating (nystagmus), due to some disease of 
the brain or medulla, such as meningitis, meningeal hem- 
orrhage, thrombosis in sinuses, tumors, hemorrhage and 
softening in various situations. The eyes may be heavy and 
sluggish, as in adynamic fevers, or continually moving, as 
in mania. They may be congested, either from some local 
irritation to the eyes themselves, as disease or foreign sub- 
stances, or from cerebral congestion. Any paralysis of ocu- 
lar muscles will produce squinting (strabismus), an inability 
to bring the axes of both eyes to bear simultaneously upon 
one point. Paralysis of upward movements would denote 
disease in the third nerve nuclei; of lateral movements, a 
lesion at the sixth nerve nuclei if there is internal squint, 
or at the third nerve nuclei if there is external squint. 
Squint may sometimes be due to spa^m produced by an irri- 
tative brain lesion, as meningitis, hydrocephalus, cerebral 
hemorrhage, tumor, or the convulsions of epilepsy. 



WHAT SHOULD BE OBSERVED ABOUT THE PUPILS? 

Whether they be contracted or dilated, equally or un- 
equally. Contraction of one pupil only would denote either 
an irritative lesion of the opposite side of the brain situ- 
ated at the third nerve nuclei, or a paralysis of the sympa- 
thetic nerve fibres due to a lesion of them somewhere in 
their course. Dilatation of one pupil would denote either a 
paralysis of the third nerve from some brain lesion or from 
an irritation of the cervical sympathetic. Extreme contrac- 
tion of both pupils occurs as a result of opium poisoning 
(during alcoholic excitement, or in the early stage of anes- 
thesia from chloroform) and irritative lesions of the third 
nerve. Dilatation of both pupils may result from poison- 
ing from belladonna or atropine, or from irritation of the 
sympathetic, during attacks of dyspnea, in the last stage 
of anesthesia. 



METHOD OF INSPECTION. 61 

HOW MAY THE EYEBROWS APPEAR? 

They may be overhanging, denoting a person possessed 
of great mental power, or corrugated, showing the individ- 
ual to be stern and high tempered, or it may be one suffering 
from great pain. They may be raised as in astonishment, or 
depressed by sadness. 

WHAT DO THE MOUTH EXPRESSIONS TEACH ? 

If the lips are compressed they denote either firmness, 
determination, anger, or that the person is suffering great 
pain and trying to control himself. If the lips are sepa- 
rated and the mouth open there may be present a bulbar 
paralysis or some nasal obstruction preventing the person 
from breathing through the nose; or it may indicate that 
the person is weak-minded. If the lips are swollen and 
bleeding it will indicate some injury; if swollen without 
bleeding it may be due to a sting from some insect or to 
angio-neurotic edema. One side of the mouth may be 
drawn up, owing to a facial paralysis of the opposite side of 
the face. The lips may be blue from defective heart ac- 
tion. Scars at the corners of the mouth may be due to some 
former syphilitic disease. If there is blood flowing from 
the mouth it may come from the lungs or stomach, or from 
injury to the tongue during an epileptic seizure, by biting. 

WHAT DO THE TEETH INDICATE ? 

If strong, large, white and regular, a person with good 
digestion. If small, discolored and crumbling, a scrofulous 
individual. Teeth may often crumble from lack of sufficient 
lime in the system, due to long-continued nervous exhaus- 
tion or neurasthenia. Hutchinson^s teeth denote hereditary 
syphilis. Teeth discolored brown are usually so colored by 
tobacco. If when the teeth are brought together in the 
upper and lower jaws there is found to be a round hole be- 
tween the upper and lower bicuspids the tooth has prob- 
ably been worn away by the stem of a clay pipe. A broken 
tooth indicates an injury, or perhaps a previous epileptic 
seizure. 

WHAT DOES THE JAW DENOTE ? 

A broad, heavy under jaw denotes great strength of char- 
acter, strong vital force and abundant determination. Such 



6^ METHOD OF INSPECTION. 

persons are not easily managed unless great care is exer- 
cised. A small, narrow, delicate jaw indicates weakness and 
lack of firmness. 

WHAT IS LEARNED FROM THE POSITION OF THE HEAD ? 

If the head be retracted, it might indicate either cerebro- 
spinal meningitis, dislocation of one of the cervical vertebrae, 
or paralysis of the anterior muscles of the neck. In paresis 
of any of the ocular muscles the head is so deflected from 
its normal position that the chin is carried in a direction cor- 
responding to the action of the affected muscles. Thus, in 
paresis of the external rectus the chin would be carried out- 
ward toward the injured muscle. When the head is so drawn 
that the ear approaches the shoulder, the occiput the tip of 
the shoulder, and the chin points to the opposite side, it is 
usually due to spasm of the sterno-cleido-mastoid muscle 
(torticollis or wry neck), or to paresis of the sterno-cleido- 
mastoid on the other side. In the latter case the chin 
always points to the affected side, on account of the unop- 
posed action of the healthy muscle on the opposite side. The 
head is drawn to one side and elevated in spasm of the trape- 
zius muscle. If the head falls forward upon the chest, bi- 
lateral paralysis of the trapezius maybe the cause; or the 
person may be in a state of stupor from the effects of dis- 
ease or from some drug. 



IF THE PATIENT BE LYING WHAT WOULD BE FIRST OBSERVED ? 

Whether he be conscious or unconscious; if conscious, 
whether lying flat, as if exhausted or in a fainting condition, 
or propped up and breathing with difficulty, as from asthma 
or some form of heart disease; if unconscious, whether 
sleeping, in a faint, or in a stupor; whether breathing 
quietly or with a loud, snoring sound (stertor), indicating 
apoplexy, fracture of the skull, or some narcotic poisoning. 
The odor of the breath will usually indicate whether alco- 
hol or chloral has produced the stupor or not. The history 
of the case should be most carefully inquired into in order 
to determine the cause of the unconsciousness if narcotic 
poisoning is suspected. In acute hydrocephalus the head 
is rolled from side to side and bored into the pillow. In 
cerebro-spinal meningitis there is a bending backward of 



METHOD OF INSPECTION. 63 

the whole body in a state of tonic spasm (opisthotonos). 
After a stroke of paralysis there may be a state of perma- 
nent flexion of the upper limbs and extension of the lower. 



IF THE PATIENT BE SITTING WHAT SHOUL,D I5E NOTICED ? 

Whether he be erect or bending over, either sideways or 
forward. Rigidity of the muscles of the back may compel 
him to sit erect; paralysis of the muscles of the back (as 
in hereditary ataxia) may prevent his doing so. The 
shoulders may be elevated, the head sunken between them, 
and the chest protruded as the result of Pott's disease. 



WHAT ATTITUDES MAY BE ASSUMED WHEN THE PATIENT IS 

STANDING ? 

The feet are placed far apart in locomotor ataxia and 
pseudo-hypertrophic paralysis in order to increase the base 
of support, thus enabling the patient to stand. Lordosis, a 
bending backward of the body, occurs in pseudo-hyper- 
trophic paralysis, progressive muscular atrophy and dis- 
eases of the vertebrae. A bending forward is often charac- 
teristic of paralysis agitans and is also most common after 
an attack of hemiplegia. 



WHAT OF THE GAIT IN VARIOUS DISEASES? 

Locomotor Ataxia. — The feet are lifted high and brought 
down heavily, the heel striking first and the ball of the foot 
last, producing the so-called double-step. There is also a 
staggering due to inco-ordination and a throwing about of 
the limbs; the eyes are kept steadily on the ground where 
patient is going to place his feet. 

Paralysis Agitans. — The patient bends forward when 
walking, steps slowly at first, and then goes faster and 
faster until there is a decided running gait, called festina- 
tion. 

Fseudo-Hypertrophic Paralysis. — The gait is much like 
the waddling of a duck, due to the weakness of the muscles; 
this prevents the patient from lifting the feet properly. 

progressive Muscular Atrophy. — There is a rolling gait, 
the body being swayed from side to side in order to bring 
the legs around. 



64 METHOD OP INSPfiCtlOI^. 

Paraplegia. — The feet are not lifted from the ground, 
but shui&ed along; the steps are short and progression is 
slow. 

Hemiplegia.— The arm at first hangs limp by the side, 
but later becomes somewhat rigid; the shoulder drops on 
the paralyzed side, the hip is raised and the weak leg is 
swung forward without any bending of the knee, the para- 
lyzed foot trailing upon the ground. 

Spastic Paraplegia. — There is a rigidity of the legs; the 
feet are shuffled along the ground in a very rigid manner, as 
if they were glued to it; the legs frequently lock and the 
patient is thrown down. 

Cerebellar Disease. — The person staggers like a drunken 
person, and walks with the feet far apart; usually he can- 
not walk without holding on to some object. 



WHAT CHARACTERISTIC CHANGES IN THE HAND ARE TO BE 
NOTICED IN NERVOUS DISEASES? 

Progressive Muscular Atrophy. — The wasting often be- 
gins in the ball of the thumb, this eminence gradually 
wasting away until it finally disappears; the muscles be- 
tween the bones of the hand shrink to such a degree that 
the bones stand out most prominently; usually a fibrillary 
twitching of the affected muscles is present. As the dis- 
ease is bi-lateral, both hands are affected alike. There is 
marked extension of the first phalanges upon the hand, with 
contraction of the second and third, giving the so-called 
claw-hand. 

Amifotrophic Lateral Spinal Sclerosis. — The hand is 
strongly flexed upon the forearm and the fingers are shut 
on the palm. It is impossible to straighten the fingers, and 
if a forcible attempt be made to do so it will cause pain. 
The affected muscles become markedly wasted, thus increas- 
ing the deformity. 

Musculo-Spiral Paralysis. — This is usually caused either 
by lead-poisoning, traumatism, or a neuritis from a chilling of 
the upper extremities, and produces the so-called wrist-drop, 
in which there is an inability to extend the hand. 

Paralysis of the Ulnar Nerve. — There is an inability to 
adduct the hand properly. Flexion is also imperfectly per- 
formed, and ability to move the little finger is suspended; 



METHOD OF INSPECTION. 65 

neither can the fingers be separated from each other, owing 
to paralysis of the muscles which this nerve supplies. 



AFTER INSPECTION WHAT SHOUI.D BE THE NEXT STEP IN 

THE EXAMINATION? 

Obtain the clinical history of the case, the age, occupa- 
tion, symptoms, when they commenced, and in what order 
they appeared, hereditary history and neuropathic tend- 
encies. 

WHAT DISEASES OCCUR DURING CHILDHOOD ? 

Cerebro-spinal meningitis, tubercular meningitis, hydro- 
cephalus, chorea, infantile cerebral paralysis, infantile spinal 
paralysis or polio-myelitis-anterior, pseudo-hypertrophic par- 
alysis and hysteria. Hereditary ataxia usually manifests 
itself during childhood, while all other diseases of the nerv- 
ous system may occur at any age. 



WHAT INFLUENCE HAS OCCUPATION UPON THE CAUSE OF 

NERVOUS DISEASES? 

Painters and workers in lead are liable to paralysis of the 
musculo-spiral nerve. Writer's cramp, gold-beater's cramp, 
cigar-maker's cramp, piano-player's cramp and telegrapher's 
cramp are forms of the so-called occupation neuroses. 



AFTER HAVING OBTAINED ALL SYMPTOMS POSSIBLE BY IN- 
SPECTION WHAT OTHER SYMPTOMS ARE TO BE NOTICED? 

All subjective symptoms that can be obtained from the 
patient, being careful to inquire particularly as to the method 
of onset, both in regard to time and severity, whether coming 
on slowly or rapidly. 

Progressive Muscular Atrophy. — This condition com- 
mences slowly and gradually increases until nearly all of 
the muscles of the body are involved. 

Apoplexy. — Occurs suddenly and without warning. 



WHAT GENERAL CONDITIONS SHOULD BE INVESTIGATED? 

Temperature, pulse, respiration, vaso-motor disturbances, 
condition of the digestive, urinary and sexual organs. 



66 METHOD OF INSPECTION. 

WHAT CHANGES TAKE PI.ACE IN TEMPERATURE IN NERVOUS 

DISEASES ? 

Temperature is elevated in all forms of acute inflamma- 
tion of the brain and spinal cord, in cerebral hemorrhage, in 
tumors of the brain, in paralyzed limbs, often in hysteria and 
after severe convulsions frequently repeated. The temper- 
ature may be higher on one side of the body than the other 
in diseases affecting the corpus striatum. The temperature 
may be lov^^ered in frequent, successive, large hemorrhages of 
the brain, and continues to fall until death takes place. 



WHAT VARIATIONS OF THE PULSE ARE FOUND ? 

When there is disease near the medulla the action of the 
heart may be accelerated, retarded or irregular. Irregularity 
sometimes occurs as an early symptom of meningitis. A 
very slow pulse, thirty or forty beats per minute, may occur 
in meningitis, apoplexy, tumor, abscess, and from increased 
intra-cranial pressure, as in hydrocephalus. Some rare func- 
tional affections may also decrease the frequency of the 
pulse. Increased frequency of the pulse occurs in neuras- 
thenia, dyspepsia, Basedow's disease or exophthalmic goitre, 
and in all inflammatory conditions. 



WHAT ANOMAI.IES OF RESPIRATION ARE TO BE OBSERVED? 

In stupor or coma from brain trouble respirations are 
lessened in frequency. They may be retarded suddenly by 
a lesion within the medulla, and slowly by a disease that 
gradually impairs the action of the respiratory centre, due 
to effusion of the blood into the fourth ventricle. In men- 
ingitis and cerebral hemorrhage there may be present what 
is called Cheyne-Stokes respiration, which is a gradual de- 
creasing of the respiration until it entirely ceases, remaining 
absent for a few seconds, then beginning almost impercepti- 
bly, increasing gradually in force and frequency until it is 
most violent, when it again gradually decreases until it 
ceases. The period of rest lasts from five to forty seconds and 
the duration of each cycle may be from fifteen to seventy sec- 
onds. The number of respirations very rarely exceeds thirty. 
It may occur in other diseases besides brain troubles, such 
as heart disease, uremia, scarlatina, diphtheria, influenza, 



METHOD OF INSPECTION. 67 

pneumonia, whooping-cough and opium poisoning. In these 
general conditions it is not so grave a symptom as it is when 
occurring in brain diseases, when it is always the precursor 
of a fatal termination. In brain diseases the patient is 
usually comatose, but in the other conditions consciousness 
usually remains. In meningitis there is another form of 
respiration, which consists of periods of deep and energetic 
breathing, which begin suddenly, gradually lessen in depth 
until they cease, when, after a period of rest, they energeti- 
cally recommence. 

WHAT VASO-MOTOR DISTURBANCES OCCUR? 

In leprous-neuritis, Raynaud's disease, and in syphilitic 
neuritis there may be ulceration, gangrene and auto-ampu- 
tation of the fingers and toes. In acromegaly there is an 
increase in size of the extremities. 

In digiti-mortui there is an irritation of the vaso-motor 
nerves, producing a spasm of the capillaries supplying the 
fingers, which causes them to be white, cold and dead. 

Angio-neurotic edema is characterized by rapid, circum- 
scribed swellings upon different parts of the body, due to 
disturbances of the vaso-motor innervation. Blushing is 
also due to vaso-motor innervation. 

Wasting of the muscles indicates disease of the motor 
nerve cells within the spinal cord, or of the nerve fibres 
proceeding from these cells. 

Changes in the nutrition of the skin may be produced by 
disease of the nerves, and are probably produced through 
the agency of the posterior roots of the spinal nerves. 



SPECIAL TESTS. 

GIVE THE TEST FOR THE ARGYLE-ROBERTSON PUPIIi. 

Place the patient before the window and direct him to 
look at an object at least twenty feet away; then ask him 
to close his eyes, placing your hands over them, keeping 
them there a moment, suddenly taking them away and ask- 
ing the patient to open his eyes. When he does so you will 
see that they do not contract to the stimulus of light. 



68 



METHOD OF INSPECTION. 



GIVE THE TEST FOR ACCOMMODATION. 

To test for accommodation, hold the finger about a foot 
from the eyes, directing the patient to watch it closely; 
then carry it farther away, and then nearer to, watching 









^ ^ 7ln 


m 






jM 


i^L^ ':^^ 


**''-,:"^:. 




JM 


^^K' 


WE h[ 




We 


* 


""jig 






1 


!?• :;>■;■ 


1' :<" •: 


: ...it.a||^ 


m^T- 


S^ ■:,■.■ ■■ 




'"■'"'^''IWipp 




w- 






,:-?«"!»* '■-::..:€; ;.,^ 




I 


-...,^^..-.*-; 




^:: "' ... . 





Figure 14. 

Testing muscular strength of leg. 

closely to see if the pupil contracts and dilates, which it will 
do according to the varying distances of the finger. 

The light-reflex may be obtained by throwing a bright 
light suddenly into the pupil. 

GIVE THE TEST FOR HEARING. 

Hearing may be tested by blindfolding the patient and 
holding the watch or tuning-fork at varying distances from 
the ear. 

HOW ARE SYMPTOMS OF DISORDERED aiOTILITY INVESTI- 
GATED ? 

Hand. — To test the strength of the muscles of the 
hand you may ask the patient to squeeze your hand with 
hiS; or he may squeeze the dynamometer. 



METHOD OF INSPECTION. 



69 



Leg. — Muscular strength of the leg may be determined 
by having the patient sit upon a chair, holding his leg out 
straight and as rigid as possible while attempt is made to 
bend it at the knee. (Fig. 14). 

Co-ordination. — To determine the power of co-ordina- 
tion of the upper extremities ask the patient to close his 
eyes, extend his arm and 
fore-finger from the 
body and bring the tip 
of his finger around to 
the end of his nose. If 
the patient is not able to 
do this it will prove that 
the power of co-ordina- 
tion is deficient. (Fig. 
15). 

Posture. — To test the 
ability to stand have the 
patient stand with both 
feet close together and 
close his eyes. If co- 
ordination is efficient he 
will begin to sw^ay and 
will fall unless he is sup- 
ported or opens his eyes. 
This is called the Brach- 
Rohmberg symptom. 
(Fig. 16). Figure 15. 

Locomotion. — To test Testing for co-ordination. 

the equilibrium in walking have the patient ^valk on a 
straight line on the floor. If co-ordination be deficient he 
wall not be able to do so. 

Tremor. — To test tremor make the patient hold his 
hands and arms out at full length with the fingers spread 
apart, and if present it w^ill be readily seen. When the 
hands and arms shake as a whole it is called vibratory 
tremor. When only the fingers or hands shake it is called 
oscillatory tremor. Fibrillary tremor is observed most fre- 
quently in the tongue and face and muscles of the ex- 
tremities 

Musde-Spasm, — Myoidema, a tonic spasm of a muscle, 




70 



METHOD OF INSPECTION. 



may be produced by a sharp stroke upon the muscle — 
usually the pectoral — which causes a bunching of the fibres 
into a small tumor, which lasts for a few seconds. It indi- 
cates the presence of an exhausting disease. (Fig. 17). 



HOW IS EXAMINATION FOK THE REFLEXES MADE ? 

Skin Reflex. — The skin, or the superficial reflexes, may 
be determined by scratching or irri- 
tating the skin. 

Plantar Refl^ex. — The plantar 
reflex is obtained by scratching the 
soles of the feet, which causes an 
involuntary jerking of the foot. 

Cremaster Reflex. — This is pro- 
duced by scratching the inner side 
of the thigh, which causes a draw- 
ing up of the testicle. 

Abdominal Reflex. — This reflex 
is produced by irritating the abdo- 
men, causing a contraction of the 
abdominal muscles. 

Epigastric Reflex. — Obtained by ' 
scratching the lower part of the 
chest. 

Scapular Reflex. — Obtained by 
irritating the skin over the scapular 
region. 

Patella Reflex. — The patella 
tendon reflex may be elicited by hav- 
ing the patient sit and cross the 
leg to be tested over the other, 
allowing the foot and leg to hang 
perfectly lax, then tapping the pa- 
tella tendon sharply with the side 
of the hand or a blunt instrument, 
which will cause the leg to ierk 

upward. ^rig. iO;. Testing for Brach-Rolimberg 

Ankleclonus. — Ihe ankleclonus symptom. 
may be produced by having the patient hold his leg out 
straight, the physician grasping the leg above the ankle with 
the left hand and the ball of the foot with the right, and 




METHOD OF INSPECTION. 



71 



suddenly flexing the foot upon the leg, when the foot will 
be thrown into a condition of clonic spasm. (Fig. 19). 
Ulnar llejiex. — The elbow jerk may be produced by the 




Figure 17. 
Testing for Myoidema. 



physician lifting up the arm of the patient at a right angle 
with the body, allowing the forearm to hang in a relaxed 
condition, then with a blunt instrument striking the triceps 
tendon. (Fig. 20). 



WHAT TESTS FOR DISORDERED SENSATIONS CAN BE MADE? 

Thermo- Anesthesia. — This may be determined by heating 
a coin and placing it on the patient, being careful not to 
have it hot enough to burn. 

Anesthesia. — This variety may be determined by pinch- 
ing or pricking the patient with a pin or an esthesiometer, 
m instrument shaped like a pair of compasses, with two 



n 



METHOD OF INSPECTION. 



sharp points and two blunt points. The patient should 
always be blindfolded when tests for anesthesia are made. 

Analgesia. — May also be 
determined by the esthesio- 
meter or a pin. 

Muscular Sense.— Mslj be 
determined by blindfolding 
the patient and asking him to 
bring his hands within about 
a foot of each other and hold 
them there. If in a normal 
condition this can be done 
with considerable accuracy. 




Fig-ure 18. 

Testing for patella reflex. 



ELECTR0=DIAQN05I5. 

HOW IS AN ELECTRICAL EXAM- 
INATION CONDUCTED ? 

Moisten the sponge elec- 
trode, placing the positive 
over any indifferent point of 
the body, and the negative 
over the paralyzed muscle or 
nerve to be tested. There 
should be an interrupting 
handle, one in which the cur- 
rent may be broken or made without removing the electrode 
from the part, upon the negative electrode. These elec- 
trodes are to be attached first to a galvanic battery. 

The negative pole is called the cathode, and the positive 
the anode. 

The current passes always from the anode to the cathode. 
It has been found that any muscle in a normal condition 
responds most readily when the cathode is closed, the con- 
traction resulting being called the cathodal-closure-contrac- 
tion. By increasing the current a little the anodal-closure- 
contraction is secured; and with still stronger current the 
anodal-opening-contraction follows — that is, a contraction 
resulting from the opening or breaking of the current at 
the anode; and with yet a still stronger current the cathodal- 
opening-contraction is excited, 



METHOD OF INSPECTION. 



73 



The normal muscle formula, then would read C. C. C.:: 
A. C. C.:: A. 0. C.::andC. 0. C.:: 

A normal nerve reaction is C. C. C.:: A. 0. C.:: A. C. C.:: 
andC. 0. C.:: 

These contractions will result from stimulation of healthy 
nerves and muscles. 

WHAT IS MEANT BY REACTION OF DEGENERATION? 

When a nerve is degenerating from a disease along its 
course or within the spinal cord it is found that the normal 
formula -of elec- 
trical reaction is 
changed and we 
may have A. C. 
C. before we have 
C. C. C; or we 
may have A. 0. 
C. before we have 
C.C. C.;in short, 
any ch ange 
which is differ- 
ent from the 
normal formula 
is called a reac- 
tion of degener- 
ation. 

Sometimes 
nerve reactions 
are largely exag- 
gerated; that is, the contractions may occur in their proper 
sequence, but with a weaker current than would be required 
in health. Under this condition there is a probability of 
some central lesion. 

If the nerve fails to produce contraction of the muscles 
with an ordinary current we know that there is a disease of 
the nerve itself or of the nerve filaments within the spinal 
cord. 

If there are produced no muscular contractions by the use 
of the faradic current we know that the motor cells of the 
anterior horns of the cord are impaired, or that the nerve 
has been severed from its connection with the spinal cord or 
has become degenerated. 




Figure 19. 

Testing for ankleclonus. 



74 



METHOD OF INSPECTION. 



In cases of paralysis from cerebral lesions electro-mus- 
cular reactions in the par- 
alyzed parts are usually 
normal. 

In paralysis of periph- 
eral nerves galvanic and 
faradic reactions are 
changed after a couple of 
weeks. The power of re- 
sponse to the faradic cur- 
rent is lost early, to a 
greater or less degree, and 
we have degenerative 
changes by the employ- 
ment of the galvanic cur- 
rent. 

In progressive muscular 
atrophy the muscles will 
respond to the faradic cur- 
rent as long as there are 
any fibres left. 

In polio-myelitis ante- 
rior, there may be a response 
to the galvanic current and not any to the faradic, as the 
nerves cannot respond quickly enough to the rapid vibra- 
tions of the faradic current, but will respond to the slower 
vibrations of the galvanic. 




Figure 20. 

Testing for ulnar reflex. 



PART nio 

DISEASES OF THE BRAIN AND ITS 
MEMBRANES. 



CEREBRAL flENINQITIS. 

WHAT IS CEREBRAL MENINGITIS ? 

An inflammation of the membranes of the brain. 



WHAT ARE THE TWO PRINCIPAL FORMS? 



Pachymeningitis, inflammation of the dura mater; and 
Leptomeningitis, inflammation of the pia mater. 



PACHYflENINQmS. 

WHAT VARIETIES OF PACHYMENINGITIS ARE THERE? 

External, in which the inflammation involves the outer 
surface of the dura mater; and 

Internal, in which the internal surface is affected. 



WHAT ARE THE CAUSES OF EXTERNAL PACHYMENINGITIS? 

The secondary results of injury to the head; extension 
of inflammation from adjacent diseases, such as caries or 
necrosis of the bone, abscesses of the middle ear or erysipelas 
outside of the skull. Sometimes no causes can be deter- 
mined. 

WHAT ARE THE SYMPTOMS OF INTERNAL PACHYMENINGITIS? 

They are usually covered by the injury or disease to 
which it is secondary. Headache, delirium, convulsions and 
fever are the main characteristic syuiptoms, in conjunction 
with those of the primary cause. 

(75) 



76 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

HOW MANY KINDS OF INTERNAL PACHYMENINGITIS ARE 

THERE ? 

Purulent, which is usually associated with inflammation 
of the pia mater; and 

Hemorrhagic, or hematoma of the dura mater, which 
consists of an effusion of blood between membranous layers 
which extend over both hemispheres, with a slight inflam- 
mation of the inner surface of the dura mater. 



LEPTOriENINQITIS. 

HOW MANY KINDS OF LEPTOMENINGITIS ARE THERE? 

Simple, tubercular, syphilitic and epidemic cerebro-spinal 
meningitis, all of which may be acute or chronic. 



WHAT ARE THE CAUSES OF ACUTE SIMPLE LEPTOMENINGITIS? 

It is most common in children under ten years of a^e, 
more frequent in males than in females. Traumatic influ- 
ences, such as laceration of the membranes and hemorrhage or 
concussion^ are direct causes; as are also adjacent diseases, 
such as caries of the bone, abscess of the middle ear, which is 
extremely common in children, and disease of the mastoid 
cells, diseases of the upper nasal passages, inflammation of 
the eye, tumors or abscesses of the brain, cerebral hemor- 
rhage, acute specific diseases, such as measles, scarlet fever, 
small pox, typhoid fever, acute pneumonia. Septicemia, 
from any cause, may also produce the trouble, this result 
being undoubtedly due to the presence of an organized virus 
within the blood which produces a toxic condition. Ex- 
posure to heat, such as sunstroke, excessive mental work 
and worry are occasional causes. 



AVHAT IS THE PATHOLOGICAL ANATOMY? 

In the early stages diffuse reddening of the pia mater, 
which is soon after followed by an opacity of the mem- 
branes. This opacity is well seen over the convexity, and 
also at the base of the brain. There are also collections of 
yellowish -white, semi-purulent lymph around the nerye 
trunks which very closely resemble tubercular granulations. 
The nerve trunks are often involved, and small hemorrhages 
may be seen in the nerve itself. The dura mater may also 



DISEASES OF THE BKAIN AND ITS MEMBKANES. 77 

he involved, either in the reddening or its under surface 
may be covered with lymph. The fluid in the sub-arach- 
noid space is sometimes increased in quantity. There may 
be an ependymitis, an inflammation of the ependyma within 
the ventricles. The choroid plexus and velum interpositum 
may also be inflamed. Spots of softening occur over the 
surface of the brain near the inflamed portions. 

WHAT ARE THE SYMPTOMS? 

There is sometimes general indisposition, languor and 
malaise, mental irritability and vomiting without known 
cause, for some days before the onset of the disease. The 
pronounced symptoms may set in suddenly and are as fol- 
lows : 

Headache. — Characterized by its severity, persistency, 
and frequent exacerbations. Even during stupor it is ap- 
parent that the patient is suffering from intense pain in the 
head. There is also a rolling about of the head, and a sharp 
shriek called the '^ hydrocephalic cry." 

Delirium. — Which may be either slight or very violent. 
It is sometimes seen in the early stages of the disease in 
those who are especially predisposed to delirium. 

Vomiting. — Is simply a rejection of food without nausea, 
projectile in character. It is a common and early symptom. 
The tongue may be clean, bowels constipated and abdomen 
retracted. 

General Convulsions. — More frequent in children, occur- 
ring at any time during the disease. There is rigidity of 
the muscles of the neck, with retraction of the head. 

Stupor. — Stupor and unconsciousness are usually present. 

Temperature. — This varies from 101° to 103°; it some- 
times reaches 105°; before death it may reach 106° and 108°. 

Pulse. — In some cases rapid, and in others slow — 60, 50, 
and 40; before death it may be 160 or 180. 

Respiration. — Just before death the Cheyne-Stokes respi- 
ration occurs. At other times it may be regular. 

Eyes. — Pupils contracted and often unequal. In the later 
stages may be dilated. 

Optic neuritis frequently occurs in meningitis at the 
base. It is due to an extension of inflammation to the mem- 
branes of the sheath and substance of the optic nerve. 



78 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

Strabismus is a common and very important symptom, 
often transient at first, and never comes to stay. It is due 
to either paralysis or irritation of the ocular nerves. 

Ptosis is often present; and also nystagmus. 

Skin. — Hyperesthesia of the skin and special senses fre- 
quently occurs, so that the least touch, noise or light will 
cause extreme suffering and pain. It is due to the ex- 
citability of the brain. Drawing the finger nail across the 
skin causes a red line to appear, which is called ^^tache cere- 
hrale^^ by Trousseau. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The symptoms above enumerated are usually clearly 
enough defined to diagnose this disease from others, and es- 
pecially would the diagnosis be certain if some of the causes 
given, such as necrosis, abscess, or adjacent disease are also 
present. We have to distinguish mainly between simple 
meningitis and epidemic cerebro-spinal meningitis and 
tubercular meningitis. The presence of the purpuric spots, 
with the characteristic brain symptoms, will readily distin- 
guish the cerebro-spinal form, while the history of tuber- 
culosis or the apparent presence of tubercle will enable us 
to diagnose that form. 



WHAT IS THE PROGNOSIS ? 

This depends upon the severity of the symptoms. If the 
fever is high, headache intense, delirium violent, followed 
by stupor, the prognosis is decidedly unfavorable. If the 
symptoms are mild, the prognosis would be more favor- 
able. In any case where coma is present death is usu- 
ally certain. Death may occur within forty-eight hours 
after the onset of the symptoms. In some cases, however, 
the onset is gradual, and w^lien so the prognosis is more 
favorable. 



EPIDEHIC CEREBRO=SPINAL HENINGITIS, OR SPOT- 
TED FEVER. 

WHAT IS EPIDEMIC CEREBRO-SPINAL MENINGITIS? 

An inflammation of the membranes of the brain and 
spinal cord occurring in epidemic form. 



DISEASES OF THE BKAIN AND ITS MEMBRANES. 79 

WHAT ARE THE CAUSES OF THE DISEASE? 

It occurs most frequently iu persons under twenty, and 
males are attacked more frequently than females. Some- 
times children are exclusively attacked. Poor sanitary con- 
ditions and overcrowding in the tenements in large cities 
are important causes. Undoubtedly some miasmatic or ma- 
larial influence induces the disease. While it is epidemic 
yet it is not contagious; but the miasmatic influences that 
produce it in one individual may also produce it in many 
others living in the same locality. It occurs most fre- 
quently during cold weather, when the people are crowded 
together more closely than at any other season of the year. 

WHAT ARE THE SYMPTOMS? 

General malaise and languor for two or three days pre- 
ceding the active symptoms, which are very similar to those 
of the simple form of leptomeningitis, intense headache, 
delirium, vomiting, convulsions, fever, and extreme retrac- 
tion and rigidity of the neck, in which there is intense 
exacerbation upon attempting to bring the head forward. 
The pain extends up into the head, down to the spine and 
into the extremities, and is increased by the slightest move- 
ment. There is also rigidity of the limbs and extreme 
hyperesthesia of the body. 

The characteristic symptom of the disease is the pres- 
ence of herpetic and purpuric spots upon different portions 
of the body, particularly upon the lower legs and forearms. 
They sometimes coalesce and form large patches of a pur- 
plish color. 

WHAT IS THE PROGNOSIS? 

It varies in different epidemics, but it is always serious. 
From thirty to eighty per cent. die. When coma occurs 
within a few hours ^of onset and the other symptoms are 
extreme death may take place within a few days, and some- 
times within forty -eight hours. 



TUBERCULAR MENINGITIS, OR ACUTE HYDRO= 

CEPHALUS. 

WHAT IZ TITBERCULAR MENINGITIS? 

It is a form of meningitis due to the presence of the 
bacillus tuberculosis within the membranes of the brain. 



80 DISEASES OF THE BKAIN AND ITS MEMBRANES. 

WHAT ARE THE CAUSES OF TUBERCULAR MENINGITIS? 

It occurs most frequently in children between two and 
ten years of age, and there is usually an hereditary history 
of tuberculosis. The presence of tubercle in other parts of 
the body predispose to it; also a scrofulous diathesis, unsan- 
itary surroundings, trauma, and great mental excitement in 
tuberculous subjects. 

WHAT ARE THE SYMPTOMS? 

Loss of flesh, gradual wasting of strength, evening rise 
of temperature, restlessness, irritability and sleeplessness may 
exist for some time before the acute symptoms come on; 
these are severe headache, occasional convulsions, delirium, 
vomiting, fever, optic neuritis. There are also marked 
symptoms of compression of the brain, due to the increased 
amount of cerebro-spinal fluid within the ventricles and the 
sub-arachnoid spaces. The child soon passes into a coma- 
tose state and dies. 

WHAT IS THE DIFFERENTIAI. DIAGNOSIS ? 

The presence of tuberculosis in other parts of the body, 
or a history of hereditary tuberculosis with the symptoms 
of meningitis, will enable us to diagnose the disease from 
any other without difficulty. 



WHAT IS THE PROGNOSIS ? 

It is usually grave. Occasionally a patient dies of some 
other condition, and upon post mortem examination, evi- 
dences of tubercular meningitis have been found, showing 
that the disease had been arrested and the patient had ap- 
parently recovered from its effects. Death usually occurs 
within two or three w^eeks from the onset of the irritative 
stage. 

CHRONIC HYDROCEPHALUS. 

WHAT IS CHRONIC HYDROCEPHALUS? 

An accumulation of fluid w^ithin the ventricles of the 
brain, when it is called internal, and in the sub-arachnoid 
spaces, when it is called external. 

It is usually a congenital disease of infancy, but may be 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 



81 



acquired. The accumulation of fluid is due to defects of 
nutrition or to mechanical causes. When due to such de- 
fects or mechanical causes, such as obstruction of the veins 
or pressure of tumors, it is the internal form, the external 
form being usually inflammatory. 



WHAT ARE THE SYMPTOMS ? 

Gradual enlargement of the head, with defective men- 
tality and symptoms of irritation of the brain, due to the 
pressure of fluid within the ventricles. Sometimes the head 
is so large at birth that the fluid within the canal has to be 
expelled before the child can be born. There is bulging of 
the forehead over the face, which is preternaturally small, 
giving a senile expression ; the occiput protrudes, the f on- 






Figrure 21. 
Chronic Hydrocephalic Heads. 

tanelles are wide open, and the head is sometimes so large 
that the child cannot hold it up on account of its weight. 
The body is usually small, due to lack of development, and 
the mental powers are much interfered with. Strabismus or 
optic atrophy are frequently present, convulsions, coma, 
and vomiting come on later, and the child may die of ex- 
haustion. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The only condition which this is like is rickets; but in 
rickets the head is square and the enlargement is not so 
great; there are also evidences of disease of the bones in other 
parts of the body. 



82 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

TREATMENT OF HENINQITIS. 

WHAT IS THE PROGNOSIS ? 

Those cases which are congenital usually die early. 
Those developing within the first year or two of life may 
last for several years; while in mild cases the disease may 
become arrested and the patient develop mentally and phys- 
ically and live a useful life. 



WHAT IS THE TREATMENT OF MENINGITIS ? 

General. — Rest, both of mind and body, is the most 
important of all. The room should be darkened and kept 
absolutely quiet, on account of hyperesthesia of sight and 
hearing. 

Local. — If the disease be caused by trauma surgical 
methods may be required. Applications of cloths wet in 
cold water, not ice water, all over the head, with hot water- 
bottles at the feet, will help to equalize the circulation and 
relieve pain. 

Dietetic. — This is extremely important. In severe 
cases nourishment must be given frequently and in small 
quantities. Milk is the main article of diet when the patient 
cannot swallow easily; it may be given iced. If there is 
not much fever beef juice, every hour, in teaspoonful doses, 
may be given. When fever is high all meat extracts or 
broths should be avoided. Oatmeal or rice boiled three or 
four hours and strained through a cloth, and given either 
hot or cold, as the patient may desire, is good. Water may 
be given in as large quantities as the patient wishes. As 
convalescence becomes established milk toast, farina, blanc 
mange, scraped beei, pancreatised meat-broth, eggs, custard, 
and wine jelly are useful. 

Remedial. — Aconite. — When due to exposure to heat. 
Chill followed by fever; full, bounding pulse; restlessness; 
anxiety; intense burning pains through the head; face red 
and puffed; sensation as if the brain were in boiling water; 
temperature 103° or higher; skin hot and dry. 

Apis. — When due to suppression of some of the exan- 
themata. Sopor interrupted by piercing shrieks; muttering 
delirium; congestion of head and face; squinting of the 
eyes; grinding of the teeth; boring head in pillow; one 



DISEASES OF THE BRAIN AND ITS MEMF^RANES. 83 

side twitching, the other paralyzed; head wet from sweat- 
ing; photophobia and diplopia; dry^ burning skin which 
grows gradually cool in places; violent fever. 

Belladoinia. — In early stages. Intense, congestive, throb- 
bing headache, with cold feet; excessive nervous excita- 
bility, the least noise or light aggravating intensely; head 
feels full of blood to bursting; stabbing as with a knife 
from one temple to the other; general convulsion; inclina- 
tion to bite; violent delirium, alternating with coma; sup- 
pression of urine, with involuntary micturition; boring of 
head in pillow, and head drawn backward; distortion of 
eyes, and redness of conjunctivae. 

Bryonia. — When there is effusion. Intense headache 
causes the child to scream from the slightest motion; face 
dark and congested; partial loss of consciousness, with con- 
stant chewing motion; must lie perfectly quiet, and does not 
want to be touched. 

Cuprum metallicum. — When due to metastasis of exan- 
themata. Violent epileptiform convulsions; vomiting of 
watery substance from the stomach; intense thirst; cold 
water temporarily prevents vomiting; great heat of head 
while child is in deep sopor; twitching and working of 
limbs; coldness of hands and blueness of fingers. 

Gelsemium. — At the very onset of the disease. Severe 
chill, followed by congestion of the brain and spinal cord; 
dilated pupils; thirstlessness; great exhaustion; staggering 
gait; dullness of speech; icy cold hands and feet; weak, 
hardly perceptible, laborious respiration; involuntary closing 
of eyelids in spite of all he can do; sweating relieves; mental 
faculties retain their activity though power over muscles is 
impaired; sometimes coma. 

Hellehorus. — Total unconsciousness, cannot be aroused; 
neck rigid, and head drawn far back; dilated plipils, insensi- 
ble to light; eyes staring and wide open; constant moving 
of one arm and one foot; grinding of teeth; constant pick- 
ing of lips and clothes. 

Hypericum. — When due to trauma, and from the effects 
of nervous shock, concussion of the brain and spine. Ver- 
tebrae sensitive to touch; headache as if the brain would be 
torn to pieces, after a fall upon the occiput; pfessive pain 
in the occiput upon motion; great dread of the slightest 
motion. 



84 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

WHAT REMEDIES ARE OF SPECIAL VALUE IN TUBERCULAR 

MENINGITIS ? 

Artemisa vulgaris, — Complete unconsciousness; piercing 
shriek; turns the eyes with violent clonic spasms; left side 
paralyzed, when the right is in a state of clonic spasm; 
drinks large quantities of water without being entirely 
aroused; head bent backwards and sideways. 

Baryta carbonica. — The child has a large head, thin, 
scrawny neck, with an apparently scrofulous diathesis; great 
mental and bodily weakness; child does not want to play; 
pressure in brain under vertex, towards occiput; tendency 
toward glandular enlargements, with hacking cough. 

Galcarea carbonica. — In children with distended abdo- 
men, wasted limbs, glandular enlargements, headache and 
sweating of head during sleep; weakness of memory; mental 
anxiety. 

ANEfllA OF THE BRAIN, OR CEREBRAL ANEfllA. 

WHAT IS ANEMIA OF THE BRAIN ? 

A deficiency of the quantity of blood within the brain. 
It may affect part of the brain only, or the whole brain, and 
may be sudden or gradual in its production. 



WHAT ARE THE CAUSES? 

General cerebral anemia may be produced when there is 
a deficiency of the quantity of blood in the whole system, 
due to hemorrhage or exhausting discharges; weakened 
heart's action; exhaustion after protracted diseases; excess 
of cerebro-spinal fluid in the brain, and cerebral tumors. 

Partial cerebral anemia may be due to obstruction of 
the bloodvessels by an embolus, thrombosis, or pressure of 
tumors; narrowing of the calibre of the vessels by syphilis 
and vaso-motor spasm. 

WHAT IS THE PATHOLOGICAL ANATOMY OF THE ANEMIA? 

There is pallor of the brain, which may be partial or 
general. The membranes are pale, and ther^ is usually 
effusion of serum in the pia mater and between the con- 
volutions; edema of the brain sometimes, and degeneration 
of the walls of the vessels. 



DISEASES OF THE BRAIX AND ITS MEMBRANES. 85 

WHAT ARE THE SYMPTOMS OF ANEMIA? 

When sudden, the patient feels drowsy, faint, with a 
cold perspiration upon the surface of the body, dullness of 
the special senses, ringing in the ears, vertigo, muscular 
weakness, pallor, nausea, and sometimes loss of conscious- 
ness; pupils at first contracted, but afterwards dilated. 

When the anemia comes on slowly there is a general 
weakness of the whole body, inability to concentrate the 
mind, sleeplessness, irritability, headache, tinnitus aurium, 
vertigo, all of which are made decidedly worse when the 
patient is in the erect position. The only comfort he can 
have is when he is lying down. 

Partial anemia causes loss of function in the part af- 
fected, and death of tissue will result if it be present. 



WHAT IS THE PROGNOSIS ? 

This depends upon the severity of the symptoms and 
their causes. If due to exhausting diseases the brain will 
recover as the patient improves in general. When due to 
embolus or thrombosis collateral circulation will some- 
times relieve the anemia in a measure and the patient will 
recover. 

WHAT IS THE TREATMENT ? 

General. — Lay the patient in the recumbent position 
with the head lower than the rest of the body. If any 
fatal termination seems imminent, inhalations of nitrite of 
amyl will be beneficial. It is far better than any alcoholic 
stimulant. Inhalations of camphor or ammonia may also 
be used. Dashing cold water in the face is often of use. 

Remedial. — Aconite. — Fainting as soon as the patient 
raises his head from the recumbent position; deathly pale- 
ness of the face; chilliness; violent palpitation of the heart. 

Camphora. — Icy coldness of the surface of the body, with 
sudden and extreme prostration; redness of the face when 
lying down, deathly pale if the patient raises up; lassitude 
and depression of spirits, with frequent yawning and 
stretching. 

Carbo vegetahilis. — Fainting after sleep while yet in 
bed in the morning, or after rising, caused by debilitating 
losses, such as blood, seminal fluid or excessive diarrhea. 



86 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

Cinchona officinalis. — Faintness after loss of animal 
fluids; head feels weak, can hardly hold it erect; faintness 
on rising, as if he would fall backwards; head inclined to 
sink backwards; on waking at night he does not dare to 
rise lest he might faint; loss of sight; ringing in the ears; 
cold surface after hemorrhages. 

Lachesis. — Tendency to faint, in women; apparent death, 
neither pulse nor breathing perceptible, after great fright or 
grief; headache over eyes and in occiput in the morning on 
rising, with faintness. 

Laiirocerasus. — Long-lasting faints; no reactive power; 
bluish tint of skin; rapid sinking of forces; restless sleep, 
gasping for breath. 

HYPEREniA OF THE BRAIN, OR CEREBRAL CON= 

GESTION. 

WHAT IS HYPEREMIA OF THE BRAIN? 

An excess of blood within the brain. It may be either 
active or passive, according as it is due to the increase of 
arterial or venous blood. 



WHAT ARE ITS CAUSES ? 

(a). Active congestion may be caused by over-action of 
the heart; contraction of the arterioles in other parts of the 
body, due to sudden exposure to cold or during a chill; dila- 
tation of the vessels of the brain which is produced by 
various toxic agents, such as nitrite of amyl, nitro-glycerine 
and alcohol; great mental excitement; worry; over-action 
of the brain; vaso-motor paralysis of cerebral vessels from 
general nerve exhaustion; exposure to heat, as in sunstroke, 
which is really the result of over-heating of the body and 
not of the action of the sun upon the head. 

(b). Passive congestion is due to a mechanical obstruc- 
tion of the vessels which prevents the return of blood to the 
body; dilatation of the heart; hyperemia of the liver; 
obstruction to the flow of blood through the lungs, which 
produces coughing; playing upon wind instruments; severe 
muscular exertion, as in lifting or straining at stool; pressure 
of tumors upon cerebral vessels; suffocation and strangula- 
tion. 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 87 

WHAT IS THE PATHOI^OGICAIi ANAT03IY IX HYPEREMIA? 

There are really no signs of any cerebral hyperemia 
observable after death. Large quantities of blood may have 
been in the brain before death but do not remain there 
after life is extinct. 

WHAT ARE THE SYMPTOMS? 

Sleeplessness; great mental excitement, which may go 
on to mania; Hushed face; eyes injected; head hot; acute- 
ness of the special senses; throbbing headache; delirium; 
screams and tears his clothes, but there are no actual delu- 
sions; temperature may be raised to 103° or higher. Such 
attacks last only a few hours. Some attacks come on simi- 
larly to those of apoplexy, in which the patient suddenly 
falls to the ground in unconsciousness. There is a tran- 
sient hemiplegia which passes away in a few days; convul- 
sions may also be present. This is called congestive apo- 
plexy. 

In mild cases of cerebral hyperemia there is simply a 
dull, full feeling in the head; drowsiness during the day 
when the patient is sitting up, but sleeplessness at night 
when he is lying down; vertigo on stooping over; head hot; 
burning face; cold feet; patient irritable and over-excit- 
able; twitching of the muscles in different parts of the 
body; numbness and weakness of the limbs; veins of the 
neck and face prominent; carotids throbbing. Bleeding of 
the nose is of frequent occurrence and relieves some. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The principal disease which may be mistaken for cere- 
bral hyperemia is cerebral hemorrhage or apoplexy. In 
the latter condition the hemiplegia persists, while in hyper- 
emia it passes away in a few days. Consciousnes is not 
impaired to such a degree in cerebral hyperemia as in cere- 
bral hemorrhage. In mild cases of hyperemia the symp- 
toms given above, when present, are sufficiently clear to 
enable us to make a diagnosis. 

WHAT IS THE PROGNOSIS? 

Life may be endangered by the intensity of the conges- 
tion; organic changes in the brain may result from com- 



88 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

plete congestiou. The majority of cases are transient, and 
are relieved when the causes which produced them are re- 
moved. 

TVH AT IS THE TREATMENT ? 

GrENERAL. — Rest of mind and freedom from all harass- 
ing occupations; excitement of all kinds should be avoided; 
change of scene and an indolent, lazy life should be rec- 
ommended upon the first appearance of the symptoms, with 
long hours of sleep and rest. 

Dietetic. — All stimulants, such as coffee, tea, alcohol and 
tobacco should be absolutely prohibited; all spiced foods, 
sweets and pastries should also be avoided; over-eating and 
late suppers should be forbidden; meat should not be eaten 
oftener than once a day, and the white meat of poultry and 
broiled fish are better than red meat; milk may cause indi- 
gestion, and hence should be taken with care; fresh, green 
vegetables are good, but corn, cabbage and tomatoes should 
be avoided. 

Remedial. — Aconite. — Active congestion; full, bounding 
pulse; burning in the interior of the head, with pale, cold 
face, covered wath perspiration; great restlessness; thirst 
for large quantities of water; delirium; especially applica- 
ble in cases which have been produced by exposure to the 
sun. 

Belladonna. — Excessive, nervous irritability, with ex- 
alted sensibilities of all the organs; the least noise or light 
is annoying; great irritability; headache as if the brain 
would be pressed out in the forehead, w^hich prevents sleep; 
throbbing of carotids; intense congestion of the head, 
better when sitting up, worse when lying down; pain in the 
head and eye-balls; eyes feel as if starting from their 
sockets; starting on falling asleep; sleepy while sitting, 
wakeful when lying down; convulsions and congestive 
apoplexy. 

Coffea. — Full of apprehension of terrible things hap- 
pening; cannot get to sleep because of ideas perpetually 
forcing themselves upon the mind; general nervous excite- 
ment. 

Glonoinum. — In congestive apoplexy, due to sunstroke; 
head feels full to bursting; sensation as if the head were 



DISEASES OF THE BllAIX AND ITS MEMBKANE3. 89 

hanging downwards, and that there was a great rnsh of 
blood to the head in conseqnence; head feels large; nausea, 
then unconsciousness, with convulsive action of the facial 
muscles; face pale; breathing stertorous; feeble pulse. 

Hijoscyamiis. — Is indicated in the milder forms of cere- 
bral congestion with symptoms similar to those of bella- 
donna, but in a milder degree. 

Niix vomica. — When due to excessive mental work or 
worry, with loss of sleep; abuse of stimulants, such as 
alcohol, tobacco; irritable, morose, sullen. 

Opium. — Passive cerebral congestion, with somnolency 
after meals, in persons predisposed to apoplexy; fainting 
turns, with vertigo whenever attempting to rise from the 
bed; great heaviness of head, making thought and writing 
difficult; congestion of blood to the head, with pulsation in 
it; coma; incomplete insensibility; will be aroused for a 
moment when addressed in a loud tone of voice and then re- 
lapses into stupor; sterterous breathing; bluish or livid face. 



APOPLEXY. 

WHAT IS APOPLEXY ? 

It is a condition which is characterized by sudden shock, 
paralysis, loss of consciousness, usually due to rupture of 
a bloodvessel, or a stoppage of the circulation of blood 
through a bloodvessel in the brain. The term apoplexy 
comes from the Greek and means, "^o strike down.''^ It has 
always been used synonymously with cerebral hemorrhage; 
but now the pathological condition which produces the apo- 
plexy is used instead of that term. Cerebral hemorrhage, 
cerebral embolism, and thrombosis of a cerebral vessel are 
the pathological states which produce this condition. 



CEREBRAL HEMORRHAGE. 

WHAT IS CEREBRAL HEMORRHAGE ? 

A hemorrhage into the brain substance, due to rupture 
of a cerebral vessel. 

WHAT ARE ITS CAUSES ? 

(1). The diseased condition of the vessel which predis- 
poses to the rupture, such as a weakening of the walls of the 



90 DISEASES OE THE BKAIN AND ITS MEMBltANES. 

vessel, which produces miliary aneurisms; atheromatous de- 
generation of the vessel, which consists of the formation of 
yellowish patches composed of fat granules on the under 
surface of the elastic coat of an artery, and which subse- 
quently assumes the consistency of gruel; syphilitic disease 
of the artery, producing weakness of the coats of the vessel ; 
endarteritis. 

(2). The causes producing these pathological condi- 
tions, namely, hereditary predisposition; sex, males suffer- 
ing more frequently than females; age, rarely occurs under 
forty, usually in the degenerated period of life; hemorrhagic 
diathesis; more common in warm climates than cold; exces- 
sive indulgence in alcohol; Bright's disease of the kidneys. 

(3). The immediate causes of the rupture, which may be 
great mental excitement, over-work, loss of sleep, lifting 
heavy weights, violent coughing, the sexual act, over-eating, 
straining at stool, great muscular exertion, such as running, 
or from recumbent position. 



WHAT IS THE PATHOIiOGICAL ANATOMY OF CEKEBKAI. HEM- 
ORRHAGE ? 

In most cases there is only one hemorrhage. Sometimes 
there are two or more, one of which is larger than the other. 
After the hemorrhage takes place a clot is formed which 
may vary in size from that of a nut to that of an egg. The 
greater part of one hemisphere may even be torn up, and all 
of the ventricles distended. The two hemispheres are about 
equally affected as regards frequency. 

The parts of the brain which are the most frequent seats 
of hemorrhage are the corpus striatum, the centrum ovale, 
the cortex, pons, and the cerebellum. Hemorrhage into the 
medulla oblongata and the crus cerebri occasionally occurs. 

In the cerebral substance we find a cavity varying in size, 
formed by the laceration of brain tissue. At first the extrav- 
asated blood is red, but as the clot forms it becomes red- 
dish-black in color, with fragments of brain tissue mixed 
with it. The cavity is usually irregular in shape and the 
brain tissue around it softened. Sometimes the blood tears 
its way into the lateral ventricles and soon distends the third 
and fourth. About the twentieth day the clot begins to 
shrink; it becomes first a chocolate, then brownish, and 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 91 

finally a reddish-yellow color, containing fat globules, pig- 
ment and other granules. The walls of the cavity also un- 
dergo a change. The mild degree of inflammation which is 
usually present leads to the formation of connective tissue 
which lines the walls, and a firm wall is thus developed. 
Connective tissue bands may extend across the cavity, unit- 
ing these walls and forming a cicatrix. The middle cerebral 
artery is the one most frequently ruptured. 

WHAT ARE THE SYMPTOMS OF CEREBRAL HEMORRHAGE? 

Premonitory symptoms may sometimes be present but 
they are rare. They consist of headache, slight vertigo, 
weakness or tingling in the limbs, slight mental changes, 
and sometimes a thickness of speech. These symptoms come 
on occasionally, lasting a few hours or days and then pass- 
ing away. 

The onset of the attack may be sudden or gradual, de- 
pending upon the rapidity with which the blood escapes 
from the vessel. The position of the clot will determine 
the character of the initial symptoms. Clots in the medulla, 
pons, or cerebellum will cause the patient to fall to the 
ground without warning as if struck by a blow. A hemor- 
rhage into the ventricles will do the same, and may some- 
times produce instant death. In the majority of cases there 
is present 

Loss of Consciousness. — This may last from a few mo- 
ments to several hours. In mild cases there may only be a 
slight mental confusion or dullness. The unconsciousness 
may go on to complete coma, with muscles relaxed and 
flaccid, urine and feces escaping, and reflex action abol- 
ished, not only in the limbs, but in the conjunctiva and iris 
as well. With this loss of consciousness there are occasion- 
ally 

Clonic Convulsions. — These are likely to be accompanied 
by paralysis of the arm, leg and face, of the opposite side 
from the lesion. Whenever convulsion is present it is 
usually owing to the fact that the hemorrhage has passed 
into the cortex, although it may occur when the hemorrhage 
is into the corpus striatum. 

Respiration. — The breathing is of a labored character, 
with puffing and blowing out of the cheeks, accompanied 



92 DISEASES OF THE BEAIN AND ITS MExMBRANES. 

by a snoring sound called stertor. In this state the patient 
may die in a few hours after the onset. Whenever Cheyne- 
Stokes respiration is present death is sure. 

Pulse.— The pulse is generally slow and often small and 
incompressible. 

Face. — The face may be flushed and turgid, or pale and 
pinched, the surface usually being covered with perspiration. 

Vojnitinf/.—Hmens may occur but it is more frequent 
when the hemorrhage is in the cerebellum. 

Temperature. — This generally falls within an hour or 
two after the onset from one to three degrees. In cases 
which are fatal within twelve hours the temperature may 
fall steadily until death. Whenever there is considerable 
rise of temperature within a few hours it is of evil omen. 
In mild cases there is usually only a slight rise of tempera- 
ture. 

These symptoms gradually pass away until only a paral- 
ysis of one side of the body is left, opposite to that of the 
lesion. After a time the paralysis, too, gradually passes 
away, the lower extremities improving faster than the upper 
extremities, until in some cases there is but little of it 
remaining. In the majority of cases there is a secondary 
sclerosis of the pyramidal tracts, which produces rigidity, 
contractures and exaggerated reflexes in the members 
affected. There is also a blunting of the mental sensibili- 
ties, and the patient is a wreck of his former self. 

Sensor 1/ Symptoms. — There are sometimes certain sensory 
symptoms, usually hemianesthesia. Anesthesia is not pro- 
found, as a rule, and the sensory symptoms may be limited 
to a sense of numbness and formication. Sensibility to 
touch is more affected than that of pain. 

Trophic Disturbances. — There may be persistent eleva- 
tion of temperature in the paralyzed parts, with reddening 
and wasting of the muscles; the skin may become edematous 
and the limb appear swollen. Sweating of the paralyzed 
limb is observed in some cases; bed-sores are developed; the 
nails become yellowish and disfigured with ridges; the hair 
of the paralyzed parts grows thick and dark, and the joints 
become inflamed. 




Horizontal section of cranium showing depressed fracture of skull, with extra- 
dural, sub-dural and interstitial hemorrhage. 

Number i. extra-dural clot: 2, laceration of brain substance, with large intra- 
cerebral clot; 3. same condition from contre coup. Tunctate hemorrliages and 
iuinute lacerations at numerous i)oints. Charactertstic of contusion of brain. 
Modified after Anger. 



PLATE V. 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 93 

WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

This is often difficult. Coma may be due to so-called 
congestive apoplexy, the effects of alcohol, opium, uremia, 
cerebral embolism, cerebral tumors, and compression of the 
brain from compressed bone. In the three latter conditions 
there is usually paralysis with the coma. 

Cerebral Embolism. — Embolism has no prodromal symp- 
toms; the coma and the paralysis are not so profound, and 
usually begin to improve within a short time. Embolism 
may occur at any age; hemorrhage usually after forty. 
The slow pulse, stertorous breathing and irregularity of the 
pupils point to hemorrhage. 

Cerebral Tumors. — The symptoms come on gradually 
and are less severe. There are also choked disk, spasmodic 
conditions, and neuralgias present during the development 
of the tumor. 

Uremia- — There are albumen and casts in the urine, 
edema and general anasarca, and there is no paralysis. 

Alcoholic Coma and Coma of Opium. — There will be an 
absence of paralysis. 

WHAT IS THE PROGNOSIS ? 

It is most grave when the coma is pro longed, the tem- 
perature rises to an extreme degree after an attack, when 
symptoms of pulmonary edema are developed, when there 
are paralysis of the sphincters, prolonged and frequent con- 
vulsions and extreme dilatation of the pupils. 

It is favorable when the coma is absent or mild and of 
short duration; when convulsions are only slight and when 
the paralysis is not complete. 



WHAT IS THE TREATMENT? 

GrENERAL. — The patient should be placed in the recum- 
bent position, with the body raised to an angle of 45°; hot- 
water bottles should be placed at the feet, and cloths wet in 
ice water applied to the head, if collapse is not present. 
Care should be taken to avoid any constriction of the cloth- 
ing about the neck. If stertor be present the patient may 
be turned on the paralyzed side, thus stopping the 
stertor. Absolute rest and quiet should be enjoined, the 



94 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

room darkened and friends kept out. If the bowels are 
loaded a high enema should be given to cleanse them as 
thoroughly as possible. 

Dietetic. — No food of any kind should be given for from 
twelve to twenty-four hours after the attack. Cold water 
may be given if the patient wishes it, or the mouth may be 
frequently wet with cold water in case the patient is uncon- 
scious, as the mouth becomes dry. Milk, egg and milk, 
made palatable with sugar and nutmeg, is first to be given 
as soon as the patient cares for food; a little every two or 
three hours is better than larger quantities at greater in- 
tervals. The liquid food is best given m teaspoonful doses, 
care being taken that the patient swallows one spoonful be- 
fore another is given, so that he does not choke. Nutri- 
ment enemata may also be given when there is paraly- 
sis of the muscles of deglutition. Thick broths, long-boiled 
rice, sago, barley with cream, custards and soft-cooked eggs 
may be given as the patient is convalescing, always being 
careful that the patient is not over-fed. Never give alco- 
holic stimulants. 

Remedial. — Belladonna. — Flushed, hot, bloated face; 
dilated pupils; fixed look; nausea; stertorous breathing; 
grinding the teeth; mouth drawn to one side; difficulty in 
swallowing; unconsciousness; convulsive movements of the 
limbs and muscles of the face; paralysis of the extremities, 
especially of one side; thickness of speech; staggering 
gait; throbbing headache; tired feeling in the limbs; weak 
memory; stiffness of the tongue. 

Gelsemium- — Threatened or actual apoplexy, with stu- 
por, coma, and usually general paralysis; headache with 
nausea; lightness of the brain; giddiness; intense passive 
congestion to the head, with nervous exhaustion; weakness 
and trembling throughout the whole system; muscles will 
not obey the will, feel bruised; pricking, tingling and 
crawling; complete relaxation of the whole muscular sys- 
tem. 

Glonoinum. — Intense cerebral congestion; vertigo, intoxi- 
cation and heaviness of the head when bending the head 
forward; reeling; trembling; falling; headache; heat in 
the head; redness of face; photophobia; injection of con- 
junctivae; flickering before eyes; buzzing in the ears; 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 95 

pulsation of carotids; nausea, then unconsciousness, with 
convulsive action of the facial muscles; face pale; breath- 
ing stertorous; feeble pulse. 

Hyoscyamus. Sudden fallmg down with a shriek; soporus 
condition; face red; lower jaw dropped; twitching of mus- 
cles; stertorous breathing; inability to swallow; involun- 
tary stool; pulse quick and full; bloodvessels swollen; 
numbness of hands after consciousness returns. 

Lachesis. — Left-sided apoplexy, especially after mental 
emotions or abuse of alcohol; blowing expiration; stupefac- 
tion or loss of consciousness; blue face; convulsive move- 
ments; tremor of extremities. 

Opium. — Coma; incomplete insensibility; extremities and 
face bluish or livid; loud, stertorous inspiration, coldness 
of skin; congestion to head, with great roaring in the ears; 
eyes open; pupils dilated; tongue drawn to one side ; speech 
impeded; inability to swallow; limbs cold and paralyzed; 
tetanic stiffness of the whole body. 

Veratrum viride. — Congestive apoplexy; feeling as if 
the head would burst open, with nausea and vomiting; ring- 
ing in the ears; blood-shot eyes; thick speech; hot head; 
pulse full, slow and hard as iron; convulsions. 

Arnica. — To be used after the active symptoms have 
passed away, to promote absorption of the clot; forgetful; 
what he reads quickly escapes his memory; thinking tardy; 
excitable and timid; indifference to everything; morose; 
easily frightened; dizziness, with sickness of the stomach; 
vertigo when shutting the eyes. 

Causticum. — For the paralytic states remaining after the 
apoplexy has been removed; paralysis and contracture of 
the lower extremities; paralysis and trembling of the hands; 
sensation of fullness in the hand when grasping anything; 
numbness of feet and toes; paralytic weakness of limbs; 
hands and feet go to sleep. 



INFANTILE MENINGEAL HEMORRHAGE, OR CERE= 
BRAL BIRTH=PALSY. 

WHAT IS MEANT BY INFANTII.E 3IENINGEAI. HEMORRHAGE? 

A hemorrhage occurring in the meninges of the brain, 
usually during birth, which causes destruction of brain tis- 



96 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

sue and produces permanent symptoms remaining during 
life. 

WHAT ARE ITS CAUSES ? 

Usually due to difficult birth, when the presentation is 
unnatural, the head being born last. The intense mechan- 
ical congestion produced by the compression of the neck in 
these cases induces the hemorrhage. In head presentations 
when there has been a tedious, difficult labor due to a large 
head in a small parturient canal, when the compression of the 
head is accordingly very great; also in cases where forceps 
have been used awkwardly in delivering the head, producing 
great compression. Violent extension of the head just after 
its birth sometimes produces it. 



WHAT IS ITS PATHOLOGICAL ANATOMY ? 

Extravasation of blood, sometimes over the convexity of 
the brain and sometimes at the base. When on the convex 
surface, it is usually bilateral. It is sometimes found in the 
median surface of the brain. Atrophy of the convolutions, 
due to long-continued compression 'by the blood, is present 
in older children. The thickest part of the extravasation is 
at the motor region. The cerebral tissue in various parts is 
sometimes injured, being broken up and infiltrated with 
blood. 

WHAT ARE THE SYMPTOMS OF INFANTILE MENINGEAL HEM- 
ORRHAGE ? 

In the majority of cases nothing is noticed the first few 
days of life, until — 

(a). Convulsions, usually either general or bilateral, 
manifest themselves, after which 

(b). Paralysis of one or more members is observed. 
There is also difficulty in holding the head up; but these 
paralytic symptoms may not be noticed to any degree until 
the patient is four or five months old, when they become 
more manifest. The paralysis may pass away in a measure, 
and only weakness of the member be left. 

(c). Spasm of the weakened muscles, producing tiexion 
of the elbow or of the wrist and fingers. Flexion of the leg 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 97 

at the knee, and of the foot may be present, preventing the 
patient from walking. 

(d). Inco-ordination of the affected members is usually 
present. 

(e). Mental weakness is manifested as the child grows 
older, and also defective articulation and sometimes perma- 
nent inability to speak; idiocy, in which there is also diffi- 
culty of swallowing and drooling of saliva. 



WHAT IS THE DIFFERENTIAI. DIAGNOSIS ? 

In cases where paraplegia is present it may be attrib^ 
uted to a spinal cord lesion, but there will usually be no- 
ticed some defect in the movements of the arms and hands, 
and when it is, remember that primary chronic spinal cord 
disease is almost unknown in young children. 

From disease of the brain before birth infantile menin- 
geal hemorrhage can be diagnosed from the fact that there 
have been no noticeable initial symptoms after birth to pro- 
duce the paralysis. 

In tumor of the brain the symptoms come on gradually. 



WHAT IS THE PROGNOSIS ? 

The damage to the brain tissue is permanent and so are 
its effects. If there is not much mental defect the child, as 
it grows older, may acquire considerable movement in the 
weakened members and to some extent overcome the influ- 
ence of the spasm. The mental condition itself will also 
gradually improve, but the child will never become as strong 
and well as other children. 



WHAT IS THE TREATMENT ? 

This can only be general, as drugs will have no effect in 
reconstructing destroyed tissue. Whatever symptoms, 
either special or general, may arise during the first years of 
life should be met by the properly indicated homeopathic 
remedy so as to alleviate as much as possible the sufferings 
of the little patient. When convulsions occur they should 
be treated as the convulsions of epilepsy, for which see 
remedies under that disease. 



98 DISEASES OF THE BRA.IN AND ITS MEMBRANES. 

CEREBRAL EHBOLISn. 

WHAT IS CEREBRAL EMBOLISM ? 

Occlusion of a bloodvessel in the brain by a plug called 
an embolus, coming from a distant part of the body and car- 
ried into the vessel by the blood. This plug, in most cases, 
comes from the heart and consists of fibrin or other foreign 
material detached from it. 



WHAT ARE ITS CAUSES ? 

Endocarditis and endarteritis, which lead to the forma- 
tion of fibrinous deposits upon the valves of the heart, are 
the primary causes of embolism. Great emotional excite- 
ment, which produces increased action of the heart, may be 
the exciting cause which precipitates the attack by detach= 
ing these fibrinous deposits and sending them into the cir- 
culation to be lodged in a cerebral artery. A history of 
acute rheumatism which produced the endocarditis is usu- 
ally present. It occurs in about equal frequency in men 
and women and between the ages of twenty and fifty, 
though it may occur at any time of life. 



WHAT IS THE PATHOLOGICAL ANATOMY? 

The most common seats of embolism are the middle cere- 
bral arteries and their branches. The next most common 
seat is the posterior cerebral and then the vertebral arteries. 
(Figs. 2 and 3). The first effect of occlusion of a vessel is to 
cut off the blood-supply to the part of the brain to which it is 
distributed. There is arterial anemia, but distension of the 
capillaries with blood from the veins, the capillaries giving 
way in places and producing fine hemorrhagic points. After 
twenty-four hours the consistency of the brain-tissue rapidly 
lessens, the nerve-cells and fibres soon break down and 
serum is effused between the fragments so that softening 
quickly takes place. 

WHAT ARE THE SYMPTOMS? 

There are no premonitory symptoms. 
Aphasia. — This is the first symptom in mild cases, and 
may be complete for an hour or two and then gradually be- 



DISEASES OF THE BKAIX AND ITS MEMBRANES. 99 

gin to pass away, though it may not wholly disappear for 
some months. 

Loss of Co)isrioi(sness. — This may occur when a large 
artery is suddenly occluded, but it usually passes away in a 
few minutes or a few hours. 

Convulsions. — These are not as severe as in cerebral 
hemorrhage, and may consist of only convulsive twitchings 
of different members of the body without a loss of conscious- 
ness. 

Paralysis. — Paralysis is usually complete for a few hours 
or days in one or more members. It is generally either a 
monoplegia or a hemiplegia. The muscles of deglutition 
and of speech may also be affected. 

Temperature. — The body heat may at first be slightly 
raised, but in a few days fever is liable to develop. 

Vomit incf. — Emesis may be present but is not a common 
symptom. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

Cerebral Hemorrhage. — The diagnosis from brain hemor- 
rhage is often difficult. In embolism the coma is not 
usually as profound, there are no premonitory symptoms, 
and the paralysis begins to improve more rapidly than in 
hemorrhage. There is also frequently a co-existence of val- 
vular lesion of the heart or aneurism of the aorta. 

Cerebral Thrombosis. — The suddenness of the onset, the 
rapid development of aphasia, the absence of prodromal symp- 
toms, the presence of heart trouble, the absence of ather- 
omatous changes in the vessels will readily differentiate em- 
bolism from cerebral thrombus. 



WHAT IS THE PROGNOSIS? 

In favorable cases all symptoms begin to pass away 
within a few days, and the patient may go on to complete 
recovery on account of the establishment of collateral cir- 
culation in branches of the occluded artery, which supplies 
the part of the brain that had been deprived of its nourish- 
ment. 

In severe cases death may take place in a few hours. If 
the paralysis does not begin to improve within forty-eight 
hours, the patient is not likely to wholly recover, as cerebral 



100 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

softening has probably commenced. Abscess of the brain 
may also be a result of embolism. 

The treatment is similar to that of cerebral hemorrhage. 



CEREBRAL THROMBOSIS. 

WHAT IS CEREBRAI. THROMBOSIS? 

It is an obliteration of the calibre of an artery in the 
brain by a fibrinous deposit formed at the seat of obstruc- 
tion. 

WHAT ARE ITS CAUSES? 

It occurs most frequently between fifty and seventy 
years of age, or during the degenerated period of life. The 
main causes are a roughening of the walls of the artery, due 
to atheroma or syphilitic endarteritis; hyperinosis, an ab- 
normal abundance of fibrin in the blood; pressure upon a 
bloodvessel so that the circulation within it is rendered ex- 
tremely slow; chronic interstitial nephritis and pyemia. 



WHAT IS THE PATHOLOGICAL ANATOMY? 

The most common seats of thrombosis are the internal 
carotid, middle cerebral, basilar, vertebral, and posterior 
cerebral arteries. The walls of the artery gradually become 
thickened, until finally the calibre of the vessel is com- 
pletely occluded. The condition of the brain from throm- 
bosis is similar to that in embolism. 



WHAT ARE THE SYMPTOMS? 

Premonitory symptoms are headache, which is generally 
dull, with heaviness of the head; giddiness; tingling, numb- 
ness and paresis of one-half the body, sometimes confined to 
one limb; weakness of memory and irritability due to lack 
of nutrition of the brain. 

When occlusion has taken place the symptoms are 
similar to those of embolism. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The time of life in which degeneration of arteries occurs, 
the evidences of syphilis^ the premonitory symptoms, which 



DISEASES OF THE BRAIN AXD ITS MEMBRANES. 101 

gradually increase, followed by weakness and ])aralysis of 
the limbs, would lead us to diagnose it as cerebral throm- 
bosis. 

Cerebral hemorrhage and cerebral embolism both occur 
suddenly; and coma is a symptom of hemorrhage but is not 
of thrombosis. 



WHAT IS THE PROGNOSIS ? 

Usually unfavorable. Cases due to syphilis may some- 
times recover. 

The treatment is like that of cerebral hemorrhage. 



CEREBRRAL SOFTENING, OR ENCEPHALOMALACIA. 

AVHAT IS CEREBRAL SOFTENING ? 

It is a necrosis of brain tissue. 



WHAT ARE ITS CAUSES ? 

Cerebral embolism, cerebral thrombosis, cerebral hemor- 
rhage, inflammation of the brain, cerebral anemia and sen- 
ility. 

WHAT IS THE PATHOLOGICAL ANATOMY? 

There are three varieties of softening, red, yellow and 
white, depending upon the amount of blood effused into the 
softened area. The most frequent seats of softening are the 
cerebral cortex, corpus striatum, and the optic thalami. 
There is more or less edema into the brain substance. The 
softened tissue w^ill be found to consist of fat-granules, 
altered blood-corpuscles, pus-cells, disintegrated nerve-tissue, 
and caseous matter. The red variety will exhibit a large 
admixture of blood-corpuscles and pigment-granules. The 
yellow and white varieties have an excess of fatty matter or 
caseous substance, and a small admixture of altered blood- 
pigments. 

WHAT ARE THE SYMPTOMS ? 

When due to embolism or thrombosis we find the symp- 
toms of these conditions, and they may be called symptoms 
of the acute stage of softening. 



102 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

The chronic stage manifests itself by loss of mental 
power, headache, more or less continuous; an inability to 
articulate properly, with a tendency to clip off words during 
conversation; an inability to maintain continuous muscular 
contraction; excitability upon the least provocation; lack of 
personal cleanliness; groundless prejudices, and all the 
symptoms of mental deterioration. Paralysis of motion 
may develop gradually, commencing in fingers and toes first 
and steadily advancing toward the. trunk. This is sometimes 
called creeping palsy. Difiicult deglutition; paresis of 
ocular muscles; and disturbances of hearing, smell and 
taste; hemianopsia and word blindness may exist. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The gradual loss of mental and physical power after an 
attack of cerebral embolism, thrombosis or hemorrhage, will 
enable us to diagnose this disease from any other. 



WHAT IS THE PROGNOSIS ? 

Always grave, the patient gradually deteriorating, both 
mentally and physically, day by day! By careful treatment, 
both hygienic and remedial, these patients may live for sev- 
eral years, but are unfortunately a burden to themselves 
and everyone around them. 



WHAT IS THE TREATMENT? 

General. — Hygienic. 

Dietetic. — Ordinary, plain, wholesome food. 

Remedial. — Homeopathic remedies, according to the 
symptoms as they arise. The mental symptoms being the 
most prominent will present indications for the remedies. 

Abrotanum. — Feebleness and dullness of mind; no ca- 
pacity for thinking, as if all bodily and mental power were 
gone; excited, loquacious, feels like shouting, exceedingly 
peevish; aversion to physical exercise; irritable; violent; 
easily fatigued by conversation or mental effort. 

Anacardium.—Loss of memory after general paralysis; 
cannot remember anything about his previous state ; imbe- 
cility; irresistible desire to curse and swear; when walking 



DISEASES OF THE BKAIX AXD ITS MEMBRANES. 103 

he feels anxious as if someone were pursuing him ; suspects 
everyone around him; anxiousness; despairs of getting 
well; despairs of being able to do that which is required of 
him; feels as though he has two wills, one commanding him 
to do what the other forbids ; a slight offense makes him 
excessively angry. 

Arsenicum. — Fear of being left alone; dread of death 
when alone on going to bed ; anxiety and restlessness worse 
after night; great fear; restlessness; trembling; cold 
sweat; prostration; very cross and despondent; vexed 
about trifles; cannot rest anywhere, moves from place to 
place; head feels confused whenever it is moved; exhaus- 
tion from the slightest exertion, must lie down ; very rapid 
sinking of strength. 

Digitalis. — Thinking difficult; forgets everything imme- 
diately; lascivious fancies day and night; profound melan- 
choly, worse by music, with frequent sighing and weeping 
which bring relief; gloomy; morose; ill humor; great fear 
of the future; insane obstinacy and disobedience; great 
anxiety as of a troubled conscience; lassitude, mental and 
bodily; faintness; exhaustion; extreme prostration; cold- 
ness of limbs; irregular, small pulse. 

Phosphorus. — Apathy; indifference; answers no ques- 
tions, or replies wrongly; takes no notice of things about 
him; answers slowly; moves sluggishly; weary of life; full 
of gloomy forebodings; dementia paralytica; weak, ex- 
hausted; silliness; idiocy. 

Picric acid. — Great indifference ; lack of will power ; dis- 
inclination for mental and physical work ; desire to sit still 
without taking any interest in surroundings ; mental pros- 
tration after the least intellectual work; cannot collect 
thoughts; quickly prostrated from using the mind. 



THROriBOSIS IN THE CEREBRAL SINUSES 
AND VEINS. 

WHAT IS MEANT BY THROMBOSIS IN THE CEREBRATi SINUSES 

AND VEINS? 

A coagulation of blood in the sinuses or veins of the 
brain, which may cause mechanical congestion, edema, 
capillary hemorrhage, and occasionally softening in the 



104 DISEASES OF THE BBAIN AND ITS MEMBRANES. 

parts of the brain from which the blood should be conveyed 
by the vessels occluded. 

WHAT ARE THE CAUSES? 

The state of the blood and circulation generally, in con- 
sequence of disease near the sinuses. The first is called 
primary, and the latter secondary thrombosis. 

Primary thrombosis occurs as a complication of maras- 
mus, diarrhea or other exhausting disease in children, and 
is hence often termed marantic thrombosis. In adults it 
occurs in the last stages of tuberculosis, cancer and general 
malnutrition. It occurs in children up to fourteen years of 
age, but most frequently during the first six months of life. 
Any prostrating disease, such as pneumonia, long-continued 
suppuration or acute specific diseases may produce it. 

Secondary thrombosis occurs as the result of caries of 
the bone, especially in diseases of the internal ear; fracture 
of the skull, when attended by inflammation of the diploe; 
meningitis; compression of a sinus by tumor; erysipelas 
outside of the skull; carbuncle of the neck, and suppurating 
eczema of the scalp. 

WHAT IS THE PATHOIiOGICAE ANATOMY? 

The sinus affected is usually filled with a clot, which adr 
heres closely to its walls. The older it is the more firmly it 
becomes attached. A recent clot is dark red and soft, but 
in a few days it becomes paler, granular and friable. It may 
be limited to one part of the sinus, or may extend to its 
whole length. The veins from which the sinus receives its 
blood are always largely distended, on account of the 
mechanical obstruction to the return of the blood, and in- 
tense congestion and edema of the part from which the 
vessels come are present. 



WHAT ARE THE SYMPTOMS? 

The symptoms are not well defined, as they are usually 
covered up by the primary disease. Headache, apathy, 
coma, vomiting, general convulsions, rigidity of the neck, 
strabismus, trembling of the tongue or limbs and epistaxis 
are the common symptoms, Mental dullness for a day or 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 105 

two, followed by repeated convulsions involving one side, are 
sometimes present. Edema about the eyelids and temples 
and protruding eye-balls occur when the cavernous sinus is 
affected. 

AVHAT IS THE DIFFERENTIAL DIAGNOSIS? 

Whenever the above train of symptoms supervenes upon 
any of the diseases mentioned as the cause of this condition 
we may be confident that there is thrombosis of the veins 
or sinuses. 

WHAT IS THE PROGNOSIS? 

It is extremely grave, but occasionally children survive 
the condition. It runs its course from a few days to six or 
eight weeks. 

WHAT IS ITS TREATMENT? 

The treatment should be directed to the condition which 
has produced the thrombosis. 



ACUTE CEREBRAL PALSY OF CHILDHOOD, OR IN= 
PANTILE HEMIPLEGIA. 

WHAT IS MEANT BY ACUTE CEREBRAL, PALSY OF CHILDHOOD ? 

A paralysis occurring suddenly in children, due to some 
organic disease of the brain. 



WHAT ARE ITS CAUSES? 



Hemorrhage into the brain or its membranes during birth 
or during childhood; embolism; thrombosis; anemia, or in- 
flammation of the brain; porencephalitis, or cavity in the 
brain, produced by a localized inflammation; simple lack of 
brain development and brain atrophy are the most common 
causes of this condition. Pneumonia, scarlet fever, measles 
and general anemia from exhausting diseases, such as cholera 
infantum, etc., are often predisposing causes. Females suffer 
more frequently than males, and the majority of cases occur 
within the first three years of life. Those cases which occur 
during birth are undoubtedly caused by trauma, 



106 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

WHAT IS THE PATOLOGICAL ANATOMY? 

This depends upon the brain disease which has produced 
the palsy. Atrophy, a cavity within the brain due to a local- 
ized inflammation, anemia and softening due to thrombosis 
and the results of cerebral hemorrhage are among the 
changes found. 

WHAT ARE THE SYMPTOMS? 

Convulsions. — These may be general or confined to one- 
half of the body or to one member which will later be in- 
volved in the paralysis, and show the cortical origin of the 
lesion. 

Paralysis. — Paralysis is the chief characteristic symptom. 
It may appear suddenly, with loss of consciousness, or it 
may come on immediately after a convulsive seizure. It may 
be confined to one member, or to the members on one side of 
the body. It may be complete for several days, and then 
improvement may commence, the leg improving more rapidly 
than the arm. In some cases the paralysis may entirely pass 
away so that no signs of it are left. 

Aphasia. — This defect of speech is a symptom which 
often complicates these palsies. It is often permanent, and 
is one of the causes of mutism. 

Mental Defects. — Defects of the mind are observable to a 
greater or less degree in all cases. They manifest them- 
selves either in loss of moral sense or may go on to extreme 
idiocy. 

Rigidity of Muscles. — Muscular rigidity is a late symptom 
of the paralysis and is associated with contractures which 
lead to the various forms of club-foot, especially equino- 
varus. Contractures of the flexor muscles of the elbow% 
wrist and fingers ma}^ be present. Wax- like rigidity of the 
member affected is a characteristic symptom. 

Exaggerated Reflexes. — These are observed in both upper 
and lower extremities. 

Athetosis. — Occasionally present in these cases. 

Defective Growth. — The paralyzed member is limited in 
its development, the limb remaining shorter and smaller in 
circumference than normally. 

Cranial Deformities. — Irregularities in development, such 
as asymmetry, are frequently seen. 



DISEASES OF THE BKAIN AND ITS MEMBRANES. 107 

WHAT IS THE DIFFEKENTIAI. DIAGNOSIS? 

This disease may be sometimes confounded with polio- 
myelitis-anterior, which is similar to it in many respects, 
both as to method of onset and in the paralysis which re- 
mains. In polio-myelitis-anterior there are no mental 
symptoms, no cranial asymmetry, no rigidity of the muscles, 
the member hanging relaxed and flaccid. The atrophy in 
this disease is also more marked than in cerebral palsy. 
There is also a loss of reflex action in the paralyzed mem- 
ber, while in cerebral palsy the reflexes are exaggerated. 

From birth palsy or infantile meningeal hemorrhage it 
is differentiated by the history of a distinct onset after birth. 



WHAT IS THE PROGNOSIS? 

The initial convulsions are sometimes followed by death. 
If the patient survives the convulsions, and if these have 
not been severe, recovery may be more or less complete. In 
the majority of cases paresis, contractures, exaggerated re- 
flexes, and mental defects are observable during the rest of 
the patient's life. Many of these cases develop epilepsy 
later in life. 

WHAT IS THE TREATMENT ? 

GrENERAL. — The little patient should be kept as quiet as 
possible during the initial stage of the disease. Cold appli- 
cations to the head maybe used during the convulsions: hot 
water to the feet, or the feet may be immersed in hot mus- 
tard water. As the little one recovers from the convulsion 
and the paralysis manifests itself the paralyzed member 
should be kept warm by wrapping.it in cotton or in a warm 
flannel blanket, as it is inclined to become cold. When 
contractures come on, they may be overcome by the use of 
the faradic current. Orthopedic surgery and appliances 
m'?.y be necessary to straighten deformed limbs. 

Educational. — This is the main treatment for the 
mental impairment due to cerebral palsy. It cannot be 
general, but must be special for the individual case. A 
teacher is required for each pupil, who should understand 
thoroughly all of the patient's i)eculiarities. Discipline is 
most essential, for unless the child be made to mind the 



108 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

moral sense will become obliterated and a wayward, unman- 
■ageable child will be the result of this neglect. The kin- 
dergarten method of training is most excellent in these 
cases and is the system used in the homes for feeble-minded 
children, where large numbers of them are to be found. 

Dietetic. — In the initial stage milk, boiled rice, oat- 
meal and flour gruels are advisable. Later, a mixed diet, 
both meat and vegetables, is necessary. Meat should be 
allowed but once a day and in small quantities. Rice pud- 
ding, corn starch, Indian meal pudding, and bread and butter, 
should form the basis of diet. These patients should be 
well fed and at regular intervals. 

Remedial. — Aconite. — When the convulsions and paraly- 
sis come on suddenly, with great nervous excitement, exces- 
sive restlessness and tossing about; jerking of leg and arm; 
grinding of teeth; heat; startings; tvvitchings of single mus- 
cles; child gnaws its fists; body rigid and bent backwards; 
fist clinched across throat ; gnashing of teeth ; eyes drawn up 
spasmodically; great muscular weakness; weariness ; prostra- 
tion and total inability to stand. 

Arnica. — Paralysis depending upon extravasation of 
blood in the brain; left-sided; general sinking of strength; 
can scarcely move a limb; sensation of being bruised in the 
paralyzed parts; bed feels too hard; paralyzed limb gener- 
ally painful. This remedy may be continued for some time 
with great benefit in helping to restore the power of the 
paralyzed member. 

Cupnim. — Convulsions beginning with cramps in the 
lower extremities, and drawing in of the fingers and toes; 
throwing about of limbs; frothing at the mouth and choking 
at the throat; restless; tossing about and constant uneasi- 
ness; starting and grinding of the teeth ; stiff ness of the whole 
body; violent spasm similar to epilepsy; red face; head and 
face puffed up; shrill shriek before the attack; paralysis of 
tongue; stuttering; deficient speech; paralyzed limbs grow 
thinner; complicated with unyielding contractures. 

Gehemiiun. — Infantile paralysis; complete relaxation of 
the whole muscular system; great drowsiness; loss of rest; 
great muscular weakness; tingling, pricking, crawling sen- 
sation in the limbs; trembling of hands when lifting them 
up; mental exertion causes a sense of helplessness from 
brain weakness; paralytic symptoms in throat and limbs. 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 109 

Galea rea carhonica. — Great loss of power on walking, 
especially in limbs, with exhausting sweat; great exhaustion 
on waking in the morning from a deep sleep; child languid, 
yellow and pale; sensation as if about to faint, with head- 
ache; paralysis of voluntary muscles; easy relapses; child 
does not continue to convalesce after the onset of the dis' 
ease; frequent severe spasms especially in the evening and at 
night, with coldness of thighs; muscular twitching, clonic 
spasm and epileptic paroxysms. 

Kali phosphoricum. — Paralysis dependent upon exhaus- 
tion of nerve power in recent cases resulting from scarlet 
fever, measles or diphtheria; general debility, with nervous- 
ness and irritability; starting on being touched or at sudden 
noises; paralysis with atrophy; paralyzing pain in the limbs, 
made worse by external warmth and motion. 

Strychnia. — For contractures, athetosis and clonic 
spasms of the muscles in the later stages. This remedy 
gives best results when used in the 200th potency. 



ENCEPHALITIS. 

WHAT IS ENCEPHALITIS? 

It is an inflammation of the substance o^ the brain, oc- 
curring very rarely alone, but usually complicated with men- 
ingitis. 

WHAT ARE ITS CAUSES? 

Idiopathic encephalitis is practically unknown. Injury 
may set up an inflammation of the brain as well as the 
meningitis. Occasionally the membranes escape and the 
brain alone becomes involved in the inflammatory process. 
Punctured wounds may cause circumscribed inflammation; 
operations upon the brain, such as trephining or the 
removal of tumors; new growths within the brain may 
cause inflammation of adjacent tissue by their pressure; 
acute diseases, such as erysipelas, diphtheria, and typhoid 
fever, are common causes. Sunstroke, great mental anxiety 
and alcoholism also produce it. 

WHAT IS THE PATHOLOGICAL ANATOMY? 

Red softening is present in all cases. The consistence 
of the brain tissue is lessened on account of the disintegra- 



110 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

tion of the tissue elements by effused liquid and the separa- 
tion of the particles. The affected area is usually swollen 
and puffed up. The nerve fibres, ganglion cells and neu- 
roglia cells become degenerated. After complete disintegra- 
tion of tissue elements there is left a fatty emulsion in the 
cavity formed by the inflammatory process. 



WHAT ARE ITS SYMPTOMS ? 

Headache, occasionally vomiting, general convulsions 
and acute delirium develop rapidly. There are great cerebral 
excitement, incoherent speech, attempts to escape from the 
bed. Temperature may range from 102'' to 106°, according 
to the intensity of the delirium. Somnolence and coma 
may follow the delirium. Mental weakness is left after the 
attack. 

WHAT IS THE DIFFERENTIAI. DIAGNOSIS? 

From acute meningitis it is differentiated by the absence 
of hyperesthesia and stiffness of the muscles of the back and 
of the neck. 

From acute mania by the height of the temperature and 
the suddenness of onset. 



WHAT IS THE PROGNOSIS? 

This depends upon the severity of the inflammation. If 
delirium is great and temperature high the result is usually 
fatal. In milder cases recovery may begin after a few 
days, but some mental weakness is usually left. 



WHAT IS THE TREATMENT ? 

General.— Absolute quiet in bed in a darkened room; 
applications of cloths wet in cold water to the head, and the 
avoidance of everything that would be apt to produce 
excitement; exclusion of all unnecessary friends from the 
room, and no loud talking or whispering in the patient's 
presence. 

Dietetic. — Avoidance of all stimulants such as tea, cof- 
fee and alcohol. Milk, eggs beaten in milk, thick broths, 
rice, oatmeal, sago, or barley boiled a long time, may be 



DISEASES OF THE BRAIN AND ITS MEMBRANES. HI 

given every two or three hours in small portions. Water, 
cold, ad libitum. 

Remedial. — Aconite. — Idiopathic cerebral inflammation, 
especially from lying with the head exposed to the direct 
rays of the sun, particularly when asleep; violent burning 
pains through the brain, especially in the forehead; fever; 
delirium; red, bloated face; burning as if the brain were 
moved in boiling water. 

Aethusa cynapium. — Delirium; imagines he sees cats 
and dogs; jumps out of the window; great anxiety and rest- 
lessness, bad humor, irritability; wants to escape; sensation 
as if both sides of the head were in a vice; headache with 
vertigo. 

Anacardium. — For the sequela of brain fever; total loss 
of memory; weakness of special senses; dullness and con- 
fusion of head; incomplete paralysis of muscles subject to 
volition; tendency to use profane language. 

Belladonna. — Rambling delirium; fear of imaginary 
things; wants to run away from them; sees ghosts, hideous 
faces, and various insects; tears the clothes from his body 
and runs naked into the streets in broad daylight. When 
closing the eyes, when not asleep, the patient sees fierce, 
wicked-looking, large animals; delirium worse in the even- 
ing; disposition to bite, spit, strike and tear things; jumping 
out of bed with fear; trying to run away and hide. ' 

Glonine. — Sensation as if the head were enormously ex- 
panded; pain ascending from below upward, and from with- 
out inward ; sensation as if warm water were running up- 
ward from the nape of the neck; sudden sensation as if the 
head were crowded with blood; brain feels as if too heavy 
and too large for the skull, with raving headache; racking 
pain with raving; heat in head; redness of face; red, pro- 
truding eyes; wiry pulse. 

Hyoscyamus. — Stupor, loss of consciousness; talking of 
the affairs of the day; picking of bed-clothes; delirium with 
physical restlessness; will not stay in bed; great restlessness; 
piercing, staring look; raving, scolding, singing; chatters 
day and night. 

Stranion'min. — Unconscious and stupid; weakened intel- 
lect; loss of memory; does not recognize his friends and 
family; confusion of mind; delirium, bland, murmuring^ 



112 DISEASES OF THE BRAIN AND ITS MEMBKANE8. 

foolish, joyful, loquacious, incoherent, chattering, with open 
eyes; frightful fancies take hold of his mind; his features 
express fright and terror; eyes red and inflamed, wide open 
and staring; shrinking look as if from fear; dilated pupils; 
pain in the head and nausea; desire for light; throbbing 
headache. 

Veratrum viride. — When caused by sunstroke, with pros- 
tration; fever; intense cerebral congestion; feeling as if the 
head would burst open; buzzing and roaring in the ears; 
double vision; convulsions of all the limbs; trembling of 
the whole body coming on suddenly; frothing at the mouth 
and violent jactitations of all the voluntary muscles. 



ACUTE SUPPURATIVE ENCEPHALITIS. 

WHAT IS ACUTE SUPPURATIVE ENCEPHALITIS, OK ABSCESS OF 

THE BRAIN? 

It is a collection of pus either on the surface of the brain 
or within its substance, forming an abscess. 



WHAT ARE ITS CAUSES? 

It is more common in men than in women, and may 
occur at any time of life, but most frequently during the 
third decade. Injury; suppurative inflammation, near or 
distant, from which septic material is carried to the brain; 
disease of the bones of the skull, and middle ear diseases; 
chronic disease of the nose; abscess of the liver; abscess of 
the lungs; imperfectly resolved pneumonia, and odium 
albicans, or thrush in the mouth. In about half of the 
cases no cause can be found. 



WHAT IS THE PATHOLOGICAL ANATOMY? 

The abscess cavity may be as large as a walnut or a hen's 
Q^g. If it be near the surface of the brain the membranes 
become thickened by inflammation and form One wall of the 
abscess. The cavity may be irregular and the capsule forms 
after a time, first being thin and delicate, then gradually in- 
creasing in thickness and firmness, its inner surface smooth 
and its substance composed of connective tissue elements. 
Outside of the capsule the brain tissue is sometimes softened 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 



113 



and there may be some fatty degeneration of the cerebral 
elements. After the capsule is formed pus cells still in- 
crease in the abscess cavity. The pus has a greenish tmge. 
The majority of abscesses have capsules, but some do not. 
Multiple abscesses may be present, but they are usually 
small. In the larger number of cases the abscesses are sin- 
gle. Abscess occurs in the cerebrum four times as fre- 







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Fig-ure 22. 

Abscess Of cerebellum. No symptoms until three hours before death. 

quently as in the cerebellum, and is rare in the pons or 
medulla. The cause of cerebellar abscesses is always sup- 
puration of the middle ear. If the abscess is of any size it 
causes pressure in the neighboring parts of the brain, but 
not to such an extent as tumor. Abscesses may become 
calcified and may remain in the brain many years. 



WHAT ARE THE SYMPTOMS? 



The first symptoms in acute cases are those of cerebral 
inflammation; but in chronic cases there may be a latent 
period which does not at first manifest itself. All degrees 



114 . DISEASES OF THE BRAIN AND ITS MEMBRANES. 

are met with from severe cerebral inflammation to a slowly 
forming abscess. 

Headache. — Headache is a frequent symptom; it may be 
extremely severe or moderate in degree. Patients have been 
known to die from the severity of the pain. It is increased 
by muscular exertion and dependent positions of the head. 
The pain usually corresponds with the seat of the disease, 
but sometimes is referred to a different part of the head. It 
may occasionally change its position from day to day, but 
usually when it once becomes seated it remains. Percussing 
the skull over the seat of the abscess will sometimes cause 
intense pain. 

Vomiting. — Emesis is generally associated with the head- 
ache. It is more frequent in cerebellar abscess. 

General Convulsions. — Convulsions may occur either at 
the beginning or at the end of the disease. If at the end, 
they are usually due to rupture of the abscess. 

Paralysis. — Paralysis occurs in some cases. It may be 
only slight and is not often complete. 

Sensation. — Not often affected. 

Mental Symptoms. — Common at the terminal period fol- 
lowing rupture; stupor, delirium, followed by coma or men- 
tal depression or failure of the mental faculties, may take 
place. 

Temperature. — Raised near the end of the disease. It is 
often accompanied by rigors, followed by sw^eating, which is 
characteristic of fever due to septic poisoning. 



WHAT IS THE DIFFERENTIAI. DIAGNOSIS ? 

It is extremely difficult to diagnose this disease, for we 
may have an ordinary attack of encephalitis which produces 
the abscess followed by a period of latency, which leads us 
to believe that the patient has fully recovered. Usually 
there is sudden rupture, with terminal symptoms. Chronic 
abscess must be differentiated from tumor. When the 
causes which produce abscess are absent but symptoms of 
it are present the diagnosis is in favor of tumor. 

From meningitis it may be distinguished by its longer 
duration and from the fact that the cranial nerves are not 
so frequently affected. The two, however, may be so nearly 



DISEASES OF THE BRAIN AND ITS MEMF3RANES. 115 

alike in their symptomatology that it will be impossible to 
differentiate them. 

From chronic ear disease it is difficult to distinguish ab- 
scess, because the meningitis is so frequently a complicating 
condition. 

Cerebellar abscess may not produce any symptoms at all, 
particularly when situated in the lobes of the cerebellum. 

An abscess within the centrum ovale may exist for years 
wdthout manifesting more than trifling symptoms, not pro- 
nounced enough to enable us to make a diagnosis. 



WHAT IS THE PROGNOSIS? 



When the diagnosis is certain the prognosis is grave un- 
less surgical measures can be brought into use. The term- 
inal stage may be precipitated at any time and death result. 



WHAT IS THE TREATMENT ? 

GrENERAL. — Surgery, when of avail, is the most important 
measure to be used. In middle ear diseases or in mastoid 
abscess a free opening may relieve the trouble. The health 
of the patient should be kept up as much as possible by 
meeting symptoms as they arise. 

Dietetic. — An abundance of good nutritious food^ con- 
sisting of meat, vegetables, and a general mixed diet, is of 
great importance before the terminal period. 

Remedial. — Belladonna. — Stabbing through the head 
as if with a double-edged knife; stabbing in the right side 
of the head; head aches as if the sutures of the skull were 
being torn open, as if a lever were being applied to force 
the bones of the skull asunder; pains come on suddenly, 
last indefinitely and cease suddenly; headache makes patient 
first blind, then unconscious; violent pain in the ear; face 
flushed; cannot keep any food on the stomach; cannot hold 
his head up on account of nausea; vomiting of watery, 
slimy, bilious fluid. 

Calcarea carhonica. — Hammering in the head, weight 
on top of head, violent throbbing on vertex, has to lie per- 
fectly still, is aroused from sleep every morning at five 
o'clock by a violent aching pain in vertex, one-sided head- 
ache with belching, internal and external sensation of cold- 



116 DISEASES OF THE BRAIN AND ITS MEMBKANES. 

ness of various parts of the head as if ice were on it, with 
pale, puffed face; severe heat in head and great orgasm of 
blood, nocturnal sweats of head; copious, exhausting sweats 
all over; hectic fever, with alternate chills and heat; sw^eats 
easily. 

Hepar sulphur. — Constant pressive pain in one-half of 
the brain, as of a plug or nail; lancinating headache, w^orse 
when walking in the open air; extreme sensitiveness of the 
scalp, cannot bear to have anything touch the head; whiz- 
zing and throbbing in the ears; darting pain in the ears; 
discharge of fetid pus from ears; over-sensitiveness to pain; 
fainting from a slight pain; hectic fever, with intermittent 
paroxysms; internal chill, with w^eariness and soreness in 
all the limbs; dry, burning heat, wath violent thirst.. 

Merciiriiis. — Congestion to the head; head feels as if it 
would burst, w^ith fullness of brain, as if constricted in a 
band; head feels heavy and swollen, as if getting larger and 
larger; hoop-like feeling; head feels as if in a vise, with 
nausea; sticking and burning deep in the ear; bloody and 
offensive matter flow^s from the ear, w^ith tearing pain; 
stitching, tearing, pressing, burning pains deep in the ear, 
extending to cheek; involuntary motions of head and hands. 

Silica. — Violent headache, with loss of consciousness or 
reason; headache wakes him up at night; loud cries, nausea 
to fainting from the severity of pain; vibratory shaking 
sensation in head when stepping hard; purulent discharges 
from the ear ; caries of mastoid process ; nausea and vomit- 
ing of what is drunk; chilliness; constant internal hectic 
fever, particularly during long suppurating processes ; sweat 
on head from the least exertion. 



INTRA=CRANIAL TUMORS. 

WHAT IS AN INTKA-CRANIAL TUMOR ? 

A tumor within the cranial cavity, either upon the inner 
surface of the cranial bones, or within the membranes of the 
brain, or in the brain substance itself. 



WHAT ARE THE CAUSES OF INTRA-CRANIAI. TUMOR ? 

The causes of these tumors are sometimes as obscure as 
the causes of tumors in other parts of the body. Males 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 117 

seem to suffer more frequently than females, except in 
sarcomatous growths. Tumors may occur at any time of 
life, but they are not common in old age. The greater 
number of cases occur during childhood and active adult 
life. A majority of those occurring during childhood are 
of a tubercular nature. They may, however, occur up to 
seventy years of age. Grliomatous growths also occur during 
active adult life, most frequently between twenty and forty 
years of age. Sarcoma occur at about the same time as 
glioma. Parasitic tumors generally occur between ten and 
tw^enty. Carcinoma is most frequently met with between 
40 and 60. Tubercular and syphilitic growths depend upon 
a constitutional dyscrasia. In the former there is usually 
an hereditary history of consumption; and in the latter, a 
personal history of syphilis. Trauma is sometimes an ex- 
citing cause of a growth, but there must be some predis- 
posing condition back of it to induce the growth. 



WHAT IS THE PATHOLOGICAL ANATOMY ? 

Intra-cranial tumors may be of several varieties; tuber- 
cular, syphilitic, glioma, sarcoma, myxoma, carcinoma, 
fibroma, osteoma, cholosteatoma, lipoma, vascular, psam- 
moma, neuroma, parasitic, and simple cysts. They occur in 
frequency about in the order named. 

Tubercular. — Occur in solid, firm, rounded masses, regu- 
lar in shape, surrounded by a softened layer of brain mat- 
ter. They vary in size from that of a pea to that of a hen's 
Qgg, and upon section present an opaque cheesy aspect, soft- 
ened here and there. They occur in the cerebral substance, 
and usually without any connection with the membranes; 
and also within the cerebellum. There is usually more than 
one tumor; sometimes two or three. 

Sijphilitic. — Irregular and nodular in shape, and vary in 
size from that of a pea to that of a walnut. They present 
upon section a cheesy appearance, irregularly distributed 
through the mass. Sometimes they appear shrunken, hard, 
fibroid, and surrounded by a hardened capsule. In favor- 
able cases sometimes only a cicatrix is left. They are situ- 
ated most commonly within the cerebellum or the pons, and 
are usually superficial and attached to the pia mater. 



118 



DISEASES OF TEE BRAIN AND ITS MEMBRANES. 



Glioma. — Have a glue-like consistency and their ele- 
ments resemble these of the neuroglia. Round, oval, fusi- 
form cells are visible. Their tint is gray or reddish-gray 
and appears very much like that of the brain tissue. Soft- 





Pigrure 23. 
Attitude in syphilitic gumma at base of 



brain. 



Figure 24. 
Same patient four years ago. 



enirig sometimes occurs which converts the growth into a 
cyst. Hemorrhage may also take place into these growths. 
They are irregular in shape and throw out processes into 
the surrounding brain tissue. They are usually single. 

Sarcoma. — May arise from the inner surface of the cra- 
nial bones, from the membranes, or from the brain. When 
within the brain substance they have a well-defined limit 
and the brain tissue is usually somewhat softened around^ 



DISEASES OF THE BRAIX AXD ITS MEMBRANES. 119 

them, so that they may be easily removed. They may be 
either hard or soft. 

Myxoma. — A mucoid growth much like a glioma. 

Carcinoma. — Usually soft and may arise from the dura 
mater or may be contained within the cerebral hemispheres. 
They infiltrate to some degree the brain substance, but usu- 
ally displace it. They are usually single. 

Fibroma. — Rare, and occur most frequently in the cere* 
bellum. 

Osteoma. — Met with in the cerebral hemispheres. 

Cholesteatoma. — A form of cystic tumor arising from 
the pia mater within the recesses of the brain. 

Lipoma. — Composed of soft, firm lobular masses of adi- 
pose tissue bound together by fibrous septa, and occur on the 
surface of the corpus callosum. 

Vascular. — Rarely met with, but when present are usu- 
ally in the cerebral hemispheres. 

Fsammoma^ or Sand Tumors. — Found in the cerebral 
meninges and contain granular calcareous concretions. 

Neuroma. — Small growths containing nerve elements. 

Parasitic. — Either hydatid or cysticerceous. The hydat- 
ids may be outside of the membranes, but they are gener- 
ally within the hemispheres. The cysticerci are within the 
membranes or in the cortex. 

Simple Cysts. — The result of hemorrhage or softening, 
their contents, effused blood or broken down nerve elements, 
having become absorbed. 

These growths produce certain pathological effects upon 
the brain. They destroy the nerve elements which are near 
them by their pressure and by the effect of the growth of 
the morbid tissue elements. They also produce distant 
pressure and affect all the parts of the brain, those nearest 
the growth being the most affected. Internal hydrocepha- 
lus is sometimes produced on account of the pressure of the 
growth in the aqueduct of Sylvius. Inflammation in adja- 
cent brain tissue is caused by the irritation of the growth. 
Meningitis may also be set up. Thinning of the cranial 
bones and actual perforation have been observed by the con- 
stant erosion of the growth. 



120 DISEASES OF THE BRAIN AND ITS MEMBRANES. 

WHAT ARE THE SYMPTOMS OF INTRA-CRANIAL TUMORS? 

They are of two kinds, general and local. 

General Symptoms. — Headache. — Generally constant, 
with acute exacerbations. It may be dull or rending, stab- 
bing, tearing, boring pain preventing sleep, and sometimes 
producing insanity; increased by any muscular exertion. It 
may be felt in all parts of the brain, and in the front or 
back of the head or on one side of the head. If the tumor 
be upon the surface of the brain, the pain generally corre- 
sponds with its situation. If the growth be in the centrum 
ovale, the pain is most often frontal; when below the ten- 
torium, the pain is occipital. Gentle tapping over the seat 
of the disease, if the tumor is superficial, will sometimes 
cause intense agony, in which case the pain is usually due 
to irritation of the meninges. 

Optic Neuritis. — Occurs in the majority of cases of intra- 
cranial tumor, wherever the growth may be; and it does not 
matter whether it be small or large. There is probably an 
extension of tissue irritation to the optic tract and nerves, 
which produces an inflammation of the papilla. The neu- 
ritis may develop rapidly or slowly, and it may go on to 
atrophy. 

Mental Symptoms. — Coma and symptoms of cerebral 
apoplexy are common in the last stages of tumor. Mental 
failure, loss of memory, great mental depression and irri- 
tability are frequent. Sometimes delusions may occur when 
the tumor is in the frontal lobe. 

Vomiting. — A common symptom, particularly w^heii the 
growth is in the medulla or in the cerebellum. 

Dizziness. — Attends the majority of cases, and is some- 
times extremely troublesome. 

Affections of Speech. — Slowness of speech, a tendency to 
separate words, difficulty of articulation, and aphasia are 
present with tumors in the white substance. 

Local Symptoms. — Paralysis. — May be either a hemi- 
plegia, monoplegia, or may affect the cranial nerves. 

Contracture. — Due to excess of myotatic irritability, fre- 
quently comes on with the paralysis and usually accom- 
panies the loss of power. Unsteadiness in standing, but 
most marked in walking, is common in tumors of the cere- 
bellum. The patient may sway backwards or forwards, or 
stagger like a drunken man. 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 



121 



('(utrnlsioiis. — May be general, with loss of conscious- 
ness, similar to ordinary epilepsy, or they may involve first 
only one member, and then gradually spread to others, or 
even be limited to the one in which it first commenced. 

Sensory Symptoms. — Hemianesthesia may be present 
with a tumor situated in the posterior part of the internal 
capsule. Numbness, tingling and pain are sometimes pro- 
duced by cerebral tumor. 

ivos.s' of Smell. — May occur from tu- 
mors in any part of the brain. 

Sfrabismns. — Either paralytic or 
spasmodic occurs when the third, fourth 
or sixth nerves is affected by the 
ffrowth. 

o 

Neiualgia. — Sometimes most intense, 
with extreme hyperesthesia, is present 
when the fifth nerve is irritated, and may 
be followed by anesthesia. 

The symptoms are always of gradual 
onset, and progress with more or less 
regularity. There may be latent periods 
during which the disease may in a meas- 
ure pass away. Sensory symptoms may 
give way to those of paralysis, and the 
nerve fibres become degenerated after a 
long period of irritation. 




WHAT IS THE DIFFERKXTIAL DIAGNOSIS? 

In every case of brain tumor we have 
to determine, first, that there is some 
organic disease of the brain; second, 
whether it be a tumor or not, if so its 
seat and its nature. The gradual onset 
of the symptoms, the headache, optic 
neuritis, vomiting, convulsions and the 
local symptoms are usually enough to 
diagnose the disease from anything else. 

Abscess of the brain has many 
symptoms similar to tumor, but the local 
symptoms are not often present, The history of suppura- 



FigTire 25. 

Attitude in cerel)ral tumor 

l)eneatli tlie cortex. 



122 DISEASES OF THE BRAIN AND ITS MEMRRAXES. 

tive disease, such as mastoid disease or middle ear abscess, 
or the results of injury, are usually present in abscess. 

To determine the nature of the growth is usually a com- 
paratively easy matter. The presence of tubercle in other 
parts of the body would lead us to believe that the growth 
is tubercular, or if there is an hereditary tubercular his- 
tory. If acquired syphilis does exist or has existed the 
tumor will most probably be syphilitic. The results of 
treatment may also determine the syphilitic character of the 
growth. Cancer or fatty tumors in other parts of the body 
w^ould probably be of the same nature as that in the brain 
when co-existing with it. A tumor which is very slow in 
developing in the cerebral hemispheres will probably be a 
glioma. 

WHAT IS THE PBOGXOSIS? 

Syphilitic tumors may be stopped. All other growths 
usually go on to a fatal termination,' unless they are of such 
a character and in such a position that surgical measures 
may be applied for their removal. 



WHAT IS THE TREATMENT? 

Surgical. — Tumors with well-defined limits, of firm con- 
sistency, and not infiltrating, such as tubercular, lipoma and 
sarcoma, situated near the surface of the brain, may some- 
times be removed with good results. 

Remedial. — Belladonna. — Headache increased at night, 
makes patient crazy, he has to run up and down, and often 
falls; incessant, dull, pressive pain on one or the other side 
of the head; violent pressing in the whole head from within 
outward; congestion to the head with delirium; red face; 
heaviness and paralytic feeling in upper limbs; numb- 
ness and pricking in one hand ; weakness of the whole arm ; 
convulsive movements of limbs; loss of co-ordination in 
muscles of both upper and lower limbs; violent convulsions 
followed by sound sleep ; attacks similar to epilepsy ; sleepy 
yet cannot sleep ; great restlessness at night. 

Barifta carhonica. — Great mental and bodily weakness; 
whining mood; stupid; pressure in brain under vertex, 
towards occiput on waking, with stiffness of neck; buzzing 
and ringing in the ears. Useful in fatty and sarcomatous 



DISEASES OF THE BRAIN AND ITS MEMBRANES. 123 

tumors; excessive irritation of all the nerves; general 
weakness of nerves and body; too weak to even chew his 
food. 

Calcarea carhonica. — Stupefying, pressive pain in the 
forehead, with confusion of senses and dullness of whole 
head while reading; tearing headache above eyes, down to 
nose, with nausea; violent throbbing on vertex; has to lie 
perfectly quiet; headache begins in occiput and spreads to 
top of head, so S3vere that she thinks head will burst and 
that she will go crazy ; tearing in bones of head ; head too 
large, f ontanelles not having closed in childhood ; weakness 
and paralysis of left arm ; nightly lacerating and drawing pain 
in the arm; frequent paralysis of fingers; heaviness and 
painful weight in limbs and great fatigue on walking; great 
loss of power on walking, especially in limbs, with exhaust- 
ing sweat; loss of flesh and general muscular weakness. 
Especially useful in tubercular subjects. 

Conium. — Complete indifference; takes no interest in any- 
thing ; sad and gloomy for days, then excited ; cannot endure 
any kind of excitement as it brings on physical and mental 
depression; lancinating pains especially in the vertex; pain 
in occiput with every pulsation as if pierced with a knife; 
sensation in right half of brain as of a large foreign body; 
paralyzed feeling in all the limbs; numbness of both fiugers 
and toes; staggering gait; muscular paralysis without 
spasms; drowsiness by day; stupid in the morning. Useful 
in fi.broma and carcinoma. 

Hj/drastis canadensis. — Moaning, with occasional out- 
cries from pain; sharp cutting in temples and over the eyes; 
myalgic headache in integument of scalp and muscles of 
neck; great despondency; intense lancinating pains in the 
head; general debility; cancerous cachexia. 

Kali iodatum. — Terrible hammering pains in forepart 
of head; lancinating and darting over left eye; pains in side 
of head as if screwed in ; vision dim and foggy ; sees objects 
indistinctly; violent jerking of limbs and muscles of thigh; 
boring, tearing pains in temporal bone; numbness of mouth; 
pains all worse at night; great general debility. Useful in 
syphilitic growths. 

Merciirius. — Tearing, drawing pains in the head, having 
their seat in the periosteum and bones; scalp tense and con- 



124 DISEASES OF THE BKAIN AND ITS MEMBRANES. 

tractive ; tearing pain from forehead to neck ; lancinating, 
tearing and stinging in bones of scalp; whole external head 
is painful to touch; trembling o£ extremities; involuntary 
jerking in limbs; weakness and weariness in limbs; general 
tremors with stammering of speech. Useful in syphilitic 
subjects. 

INTRA=CRANIAL ANEURISM. 

WHAT IS AN INTKA-CRANIAL ANEURISM? 

It is a tumor formed by a localized dilatation of an 
artery within the cranial cavity. 



WHAT ARE ITS CAUSES ? 

It occurs more frequently in males than in females, and 
between ten and sixty years of age. There are sometimes 
hereditary tendencies toward the formation of aneurism. 
Injury, such as a blow or fall on the head, causing an ar- 
teritis which may so change the wall of the artery that it 
becomes easily dilated. Syphilis and embolism are fre- 
quent causes. 

WHAT IS THE PATHOLOGICAL, ANATOMY? 

The walls of the artery are usually thin and bulging at 
different points, producing an aneurism. The aneurism may 
vary in size from that of a pea to that of a hen's egg. 
They are usually round, sometimes oval. As it growls in 
size it compresses the brain tissue and thus damages it to a 
greater or less degree. It is this pressure which produces 
•the symptoms. In case of rupture the blood escapes into 
the cerebral tissue and into the membranes. The middle 
cerebral artery is most frequently involved, and next the 
basilar. The internal carotid, anterior cerebral, posterior 
cerebral, vertebral, and the communicating arteries may 
also be involved. 

WHAT ARE THE SYMPTOMS? 

Aneurism of considerable size may exist within the brain 
for many years without giving any indication of its pres- 
ence until rupture takes place. Where symptoms are 
present they are usually those which are characteristic of 
tumor^ such as headache, vomiting, giddiness, optic neuritis, 



DISEASES OF THE BRAIN AND NERVOUS SYSTEM. 125 

affections of speech, mental disturbances, symptoms of 
pressure upon the cranial nerves and other local symptoms. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

It is impossible to diagnose mtra-cranial aneurisms until 
pressure symptoms are present, and even then we may not 
be able to differentiate between aneurism and tumor until 
we are able to distinguish the aneurismal murmur which in 
rare cases has been heard. 



WHAT IS THE PROGNOSIS ? 

When the diagnosis is certain the prognosis is always 
grave, and it is impossible to tell at what moment death 
may occur from rupture. 



AVHAT IS THE TKEAT3IENT? 

General. — Avoid as much as possible any excessive 
muscular exertion, such as lifting heavy weights, or run- 
ning, stooping over, or lying with the head low. All mental 
worry should be avoided as much as possible, and every 
means used to prevent either active or passive congestion of 
the brain. 

Dietetic. — Grood, plain, wholesome food without much 
sweets or pastries, which are likely to produce hyperemia 
of the liver and, secondarily, hyperemia of the brain. 

Remedial. — The remedies used in intra-cranial tumors 
will be found useful in the treatment of aneurisms. 



DEGENERATIONS OF THE BRAIN. 



CYSTIC DEGENERATION OF THE BRAIN. 

WHAT IS CYSTIC DEGENERATION OF THE BRAIN? 

It is the formation of cavities within the white sub- 
stance of the brain. These cavities are probably enlarged 
peri-vascular spaces, and are usually filled with broken 
down nerve tissues and the remains of small extravasations 



126 DEGENERATIONS OF THE BRAIN. 

due to the rupture of vessels within them. These cavities 
usually occur in the shrunken brains of the old, and there 
may be numbers of them. It does not matter how great 
the number of these cavities, for they usually give no 
symptoms. 

CHRONIC PROGRESSIVE SOFTENING OF THE BRAIN. 

WHAT IS CHRONIC PROGRESSIVE SOFTENING OF THE BRAIN? 

It is a slow progressive softening involving the white 
matter of the brain, and is a primary process. The change 
is a simple white softening, and the microscope will show 
the products of degeneration. The areas affected are usually 
sharply limited from the normal brain tissue. While the 
softening usually commences in the white matter it may in 
some cases involve the gray matter of the cortex. 



WHAT ARE THE CAUSES? 

It occurs in both sexes, and is most frequent between 
sixty and eighty years of age. No special causes have as 
yet been determined as the disease is rare. 



WHAT ARE THE SYMPTOMS? 

A gradually increasing hemiplegia and hemianesthesia. 
The weakness may commence in one member and gradually 
involve the whole side without any special sensory loss at 
first. Numbness, tingling, and formication in the limbs 
are sometimes present. Rigidity of the members paralyzed 
may come on at first, but it passes away when the paralysis 
is fully developed. There may be attacks of vertigo, which 
soon pass away. The intellect may not be much affected, 
though in some cases it may become blunted toward the last. 



WHAT IS THE PROGNOSIS? 

It is invariably fatal, running its course in from two or 
three months to two years. 

Little can be said with regard to treatment. The main 
method of procedure is to nourish the patient as much as 
possible, and to use such remedies as may be indicated from 
time to time for the general symptoms. 



DEGENERATIONS OF THE BRAIN. 127 

DISSEniNATED OR INSULAR SCLEROSIS, OR nUL= 
TIPLE SCLEROSIS. 

WHAT IS DISSEMINATED SCLEROSIS? 

It is the formation of scattered islets of hardened tissue 
due to proliferation and increase of connective and neuro- 
glia tissue in the brain and spinal cord. 



WHAT ARE ITS CAUSES? 

It occurs in both sexes with about the same frequency 
and at any period of life, but especially in the first half of 
adult life. The larger number of cases commence between 
twenty and thirty-five. Heredity is an occasional cause, such 
as a family history of insanity, epilepsy, etc. Many cases de- 
velop without any cause that can be determined. Exposure 
to cold, mental worry, over-exertion, both mental and phys- 
ical, acute diseases and trauma are often exciting causes. It 
has been known to follow typhoid fever, small-pox, diph- 
theria and erysipelas.- One of the author's cases occurred 
during pregnancy. 

WHAT IS THE PATHOLOGICAL ANATOMY ? 

The hardened islets are irregular as regards their loca- 
tion, being scattered anywhere through the central nervous 
system, but almost exclusively in the white matter. They 
are irregular in shape, and in size are as large as a pea or 
may be as large as a walnut. They are reddish-gray in 
color. The central ganglia are frequently involved in the 
sclerosis. The cerebellum has bat few hardened patches. 
In the spinal cord the diseased spots appear on the surface 
and extend for some distance into the substance of the cord. 
They consist of fibrous tissue and are of firmer consistency 
than the surrounding tissues. 



WHAT ARE THE SYMPTOMS? 



As these islets of sclerosis are widely scattered the symp- 
toms are correspondingly various. Paresis which goes on 
to paralysis in different members of the body, associated 
with jerky irregularity of movement, are prominent symp- 
toms at the beginning of the disease. 



128 DEGENERATIONS OP THE BRAIN. 

Paresis. — Begins usually as a simple weakness in one 
limb, or maybe both limbs on one side, but the legs are 
most frequently affected. After a time this weakness be- 
comes an absolute loss of power. 

Intention tremor. — An irregular, jerky tremor upon at- 
tempting to use the affected member. If the patient tries 
to lift a glass of water to his lips he is likely to spill its 
contents on account of this tremor. It ceases entirely when 
the patient is at rest. 

Nystagmus. — One of the manifestations of tremor. 

Exaggerated Reflexes. — Present, with a spastic condition 
of the lower extremities. 

Articulation. — Jerky in character, syllables being dropped 
or indistinctly pronounced, due to inco-ordination of the 
muecles of the tongue. It is sometimes called " scanning 
speech." 

Oscillation of the Head. — May be so pronounced that the 
patient is not able to hold his head up or even to sit up. 
Sometimes the muscles of the trunk are involved in like 
movements. 

Impair moit of Sight. — Occurs in one or both eyes, with- 
out any demonstrable changes in the optic nerve, at first 
due to an islet of sclerosis in the optic nerve or in the optic 
chiasm. Later, however, atrophy of the nerve occurs. 

Paralysis of the Eye Muscles. — Due to a paralysis of the 
sixth nerve, occurs in a large number of cases, and some- 
times there may be paralysis of the third nerve. 

Handwriting. — Jerky and tremulous like the speech, 
due to inco-ordination. 

Figrure 26. 

Handwriting in disseminated sclerosis. 

Anesthesia. — Irregularly distributed anesthetic patches 
may occur whenever a sensory nerve is affected. 

Mental Changes. — Characterized by failure of memory 
and an undue complacency and contentment which are en- 
tirely out of place with the existing condition of affairs. 




DEGENERATIONS OF THE BRAIN. 129 

Headache, dizziness and vertigo are usually present to a 
greater or less degree. 

WHAT IS THE DIFFEKENTIAI. DIAGNOSIS? 

The characteristic symptoms of jerky inco-ordination, 
combined with progressive weakness in the limbs and nys- 
tagmus, make it easy of diagnosis. 

In paralysis agitans the tremor is regular in character, 
and persists even when the patient is quiet. 

Disseminated sclerosis is sometimes confounded with 
hysteria, but the jerky inco-ordination, the exaggerated re- 
flexes and the nystagmus should enable one to determine 
the difference between the two. 



WHAT IS THE PROGNOSIS? 

Always grave. In some cases it progresses steadily from 
first to last toward a fatal termination, though usually periods 
of apparent rest alternate with those of progress. The 
duration is from two to fifteen years, but the average is 
from three to six years. The cause of death is the involve- 
ment of the medulla by the sclerosis, which interferes with 
its function, preventing swallowing and even respiration 
itself. 

AVHAT IS THE TREAT3IENT? 

General. — Patients suffering from this disease should 
exert themselves as little as possible, rest a great deal, and 
take life easy. Hygienic measures should be rigidly en- 
forced. Electricity should not be used when spastic symp- 
toms are present. 

Dietetic. — Good, nourishing, wholesome food, without 
pastries or sweets, at regular intervals and in sufficient 
quantity, is the proper diet for such cases. 

Remedial. — Arf/entuni nitricmn. — Great weakness of 
mind; tremulous weakness accompanied by general de- 
bility ; periodical trembling of the whole body ; lassitude 
and weariness of forearms and legs; legs feel as if made of 
wood; inco-ordination of muscles with staggering gait. 

Baryta carhonica. — Great mental and bodily weakness 
with glosso-pharyngeal paralysis; paralysis of upper and 



130 DEGENERATIONS OF THE BRAIN. 

lower extremities; great drowsiness during the day; weak- 
ness of sight; irregular contraction of pupils. 

Causticum. — Paralysis of single parts or single nerves 
coming on gradually ; obscuration of sight as if a veil were 
drawn before the eyes; impairment of deglutition and 
speech; contraction of muscles; exaggerated reflexes; un- 
steady walking. 

Crotalus horrid us. — Tremulous weakness all over; easily 
tired by slightest exertion ; sudden and great prostration of 
vital force; starting, jerking, trembling and cramps of lower 
extremities, with coldness of feet; contraction of flexors; 
numbness of hands and feet. 

Gelsemium. — Paralytic symptoms in throat and in limbs; 
complete relaxation and prostration of the whole muscular 
system, with entire motor paralysis; unsteady gait; staggers 
as if drunk, due to inability to control muscular move- 
ments; eye-balls oscillate laterally when using them (nys- 
tagmus); paresis of ocular muscles; great heaviness of lids. 

Ignatia. — Mentally and physically exhausted by long 
continued grief; trembling of hands when writing; great 
weakness of whole body; paralysis after great mental emo- 
tion; trembling of limbs with gre'at langour; staggering 
gait; jerking and twitching in various parts of muscles. 

Silica. — Trembling of legs with extreme nervousness; 
walks like a hen (grassus gallinaceus); weakness of knees; 
cramps in calves of the legs; sense of great debility; wants 
to lie down; limbs go to sleep easily. 

Tarentula. — Weakness of legs, not allowing feet when 
walking to be placed squarely on the ground; difficulty to 
move legs, they do not obey the will ; disorderly and irregu- 
lar muscular movements of limbs; trembling of the body. 



PROGRESSIVE BULBAR PARALYSIS. 

WHAT IS PROGRESSIVE BULBAR OR LABIO - GLOSSO - I.ARYN- 

GEAI. PARALYSIS? 

A progressive degeneration of the motor nerves which 
supply the muscles of the mouth, fauces, pharynx and 
larynx, producing an associated palsy of these muscles. 
The nerves involved are the fibres of the facial which sup- 
ply the lower part of the face, the hypoglossal which 



DEGENERATIONS OF THE BRAIN. 131 

vSiip plies the tongue, the spinal accessory which supplies the 
larynx and palate, and the glosso-pharyngeal which supplies 
the pharynx. 

WHAT ARE THE CAUSES? 

Men and boys are more liable to it than w^omen and 
girls. It occurs more frequently in the second half of life. 
Mental worry and depression, combined with great physical 
exhaustion, exposure to cold, lack of proper food, injury, 
sach as a blow upon the back of the neck, and excessive use 
of the muscle^ inv^olved are some of the immediate causes. 



WHAT IS THE PATHOLOGICAL ANATOMY? 

The muscular fibres present fatty and granular degen- 
eration and are much narrower than normal, some fibres 
more so than others. The nuclei of the sheaths and of the 
interstitial tissue are increased, and a reddish pigment, the 
resuJt of degeneration of fibres, is scattered throughout the 
muscle. The main lesion is found in the nuclei of origin 
of the hypoglossal, glosso-pharyngeal, pneumogastric and 
spinal accessory nerves within the medulla or bulb, hence 
the name of the disease. There is sometimes degeneration 
of the anterior pyramids. The nerve cells are wasted and 
their processes shrunken. 



WHAT ARE THE SYMPTOMS? 

The first noticeable symptom is indistinctness of articu- 
lation. The patient is unable to articulate the consonants 
1, n, t. The tongue cannot be protruded from the mouth 
but a little way. The lips are also weak, and the patient 
cannot sound the consonants b, p, m. He cannot whistle. 
The under lip hangs down and the saliva dribbles from the 
mouth. There is difiiculty in swallowing solids . After a 
time the lips are paralyzed to such a degree that the patient 
cannot shut his mouth. The expression of the patient's 
face changes: the upper part has an expression of anxiety 
and suffering, and the lower part is motionless and without 
expression. There is great dryness and stiffness about the 
throat, and after a time the ability to swallow is lost and 
articulation also. Mastication is difficult, because the 



132 DEGENERATIONS OF THE BRAIN. 

tongue is not able to guide the food in the mouth. There 
are no sensory symptoms and the mind is unimpaired; 
there is, however, a great tendency to weep, which might 
naturally be the case when the patient realizes the hope- 
lessness of his condition. 



WHAT IS THE DIFFEREXTIAI. DIAGNOSIS? 

The muscles affected, the slowness of onset, and the 
progressive character of the disease distinguish it clearly 
from any other condition. 

Tumors within the membranes are differentiated from 
bulbar paralysis, by the symptoms beginning upon one 
side, while in bulbar paralysis they are bilateral. 

From diseases of the brain, such as polio-encephalitis, 
softening, and cerebral lesions, it is diagnosed by the ab- 
sence of hemiplegia and of any sensory symptoms. 



WHAT IS THE PfgOGNOSIS? 

Grave. It usually goes on to complete degeneration of 
the nuclei of the bulb, producing such a degree of paralysis 
that the patient is not able to take the proper nourishment 
and dies from inanition, or on account of the paralysis of 
the muscles of the throat particles of food pass into the 
bronchi and a fatal bronchitis is set up. 



WHAT IS THE TREATMENT? 

General. — Rest, massage and faradization of the mus 
cles of the throat and tongue, and abundant nourishment 
are of great importance in these cases. The so-called '' rest 
cure '' sometimes retards the progress of the disease and is 
therefore of value. 

Dietetic. — As the disease progresses the patient is not 
able to take solid food, but broths, long-boiled rice or oat- 
meal, milk, soft boiled eggs, gruels and meat, bread, pota- 
toes, vegetables, macerated in a mortar by adding broth, are 
of value. 

Remedial. — Anacardium. — Unable to speak; makes only 
unintelligible sounds; apt to choke when eating and drink- 
ing; swallows food and drink hastily ; heaviness of tongue 



DEGENERATIONS OF THE BRAIN. 133 

and sensation as if it were swollen; water flows out of the 
mouth; low-spirited; disheartened; despairs of getting well. 

Barifta carhonica. — Paralysis of tongue; inability to 
speak; tongue cracked and sore; dryness of mouth; hawks 
mucus; water runs from the mouth all day; much 
troubled with tongue phlegm; salivation; inability to swal- 
low. 

Belladonna. — Paralytic weakness of organs of speech; 
inarticulate speech from hindered mobility of the tongue; 
trembling of the tongue when protruded. 

Causficmn. — Speechlessness from paralysis of the organs 
of speech; stuttering; difficult, indistinct speech; paralysis 
of tongue; saliva runs from the mouth more after eating; 
paresis of laryngeal muscles and vocal chords; laryngeal 
muscles refuse to act; sudden loss of voice. 

Cocciilus. — Tongue seems paralyzed; speech difficult; par- 
ralysis of face, tongue and pharynx; great difficulty in 
swallowing; has to speak slowly in order to be understood. 

PliosplioruH. — Speech difficult and weak; answers ques- 
tions with difficulty; stutters when endeavoring to articu- 
late; painless twitching of the muscles of the tongue; much 
watery saliva in the mouth. 

Mercurius. — Speech difficult on account of trembling of 
mouth and tongue; quick, stuttering, tremulous speech; 
saliva fetid, or tastes metallic, coppery, tenacious, soapy and 
stringy ; fetid odor from the mouth. 



ATROPHY OF THE BRAIN, OR MICROCEPHALY. 

WHAT IS ATROPHY OF THE BKAIX? 

A wasting of the brain substance which may involve the 
whole brain or only a part of it. 

Atrophy of the whole brain is congenital, while partial 
atrophy may be acquired. 

The skull is usually small as well as the brain, some hav- 
ing thought that the small skull was the cause of the small 
brain, but this is probably not true, as the skull grows as 
rapidly as the brain. 

There is also more or less atrophy in the senile brain, 
^hich may not be altogether a diseased condition. 



134 



DEGENERATIONS OF THE BRAIN. 



Mental defects are constant in this condition and the 

subjects are usually idiotic. 
Weakness, athetoid move- 
ments, and inco-ordination 
also co-exist. 

This condition of the 
brain is not a distinct dis- 
ease and has no place in neu- 
rology as such. Its causes 
are difficult to define and the 
treatment for the condition 
is unsatisfactory, as nothing 
can be done. 




HYPERTROPHY OF THE 
BRAIN. 

WHAT IS HYPERTROPHY OF 
THE BRAIN? 

A condition in which the 

brain is of abnormal size. 

Pigrure 27. Hydrocephalus and rickets 

Microcephalic Idiot. ^j-e usually causes of this 

condition. The brain sometimes increases abnormally in 

older children and in adults, but nothing is known of the 

causes. 

The treatment may be directed toward the relief of the 
hydrocephaloid condition or of the rickets if these causes 
have produced the trouble. 



PART IV. 

DISEASES OF THE CRANIAL NERVES. 



OLFACTORY. 

WHAT CONDITIONS RESULT FROM DISEASE OF THE OLFAC- 
TORY NERVE? 

Anosmia. — When not due to a disease of the nasal mu- 
cous membrane anosmia may be produced by lesion in the 
olfactory nerve in the medulla, or in the olfactory centre in 
the cortex of the brain, or it may be produced by a menin- 
gitis, tumor of the brain, or hydrocephalus. It sometimes 
occurs in locomotor ataxia as the result of atrophy of the 
olfactory nerve. Excessive stimulation of the olfactory nerve 
may cause its paralysis. Tumors of the brain may produce 
an olfactory neuritis. Anosmia may be bilateral or uni- 
lateral. In the former case, it is called hemianosmia. 

Hifperosmia. — A symptom which often manifests itself 
in hysteria, and in hypnotized subjects. 

Parosmia. — Also a symptom of hysteria, or it may be an 
hallucination indicating the beginning of insanity. Every- 
thing smells alii:e, and everything has a disagreeable odor. 



WHAT IS THE TREATMENT ? 

Remedial. — For awosm^a.• Anacardium, Calcarea, Hyos- 
cyamus, Natrum muriaticum. Plumbum, Silica and Zin- 
cum. 

For hyperosmia : Agaricus, Aurum, Belladonna, Coffea, 
Conium, Mezereum, Nux vomica. Sepia and Tabaccum. 

For parosmia: Nux vomica, odor of cheese; Anacardium, 
Calcarea and Yeratum viride, odor of manure; Aurum, Bella- 
donna, Creosote, Kobalt and Nitric acid, putrid odor; Pulsa- 
tilla, odor of tobacco; Agnus castus, odor of musk, 

(135) 



136 DISEASES OF THE CRANIAL NERVES. 

OPTIC NERVE. 



INFLAIVI/VIATION OF THE OPTIC NERVE, OPTIC 
NEURITIS OR PATILLITIS. 

WHAT ARE THE CAUSES OF OPTIC NEURITIS? 

Tumors of the brain are the most frequent cause. Men- 
ingitis, abscess, thrombosis, myelitis, nephritis, diabetes, 
multiple neuritis, lead poisoning and hemorrhage are other 
causes. 

WHAT ARE THE SYMPTOMS? 

No subjective symptoms may be reported by the patient, 
as the sight may remain good for a long time. The disease 
will have to be determined by the ophthalmoscope. The 
ophthalmoscopic symptoms are, increased redness of the 
disc, with its borders obscured, swelling, and later, the form 
of the disc is entirely lost. The arteries are partly concealed 
by the swelling of the disc. The inflammation may go on 
and produce atrophy of the optic nerve. 



WHAT IS THE PROGNOSIS ? 



This depends upon the disease of the brain which pro- 
duces it. In some cases the inflammation passes away and 
vision is left intact. In unfavorable cases there is finally 
absolute blindness. 



WHAT IS THE TREATMENT ? 



The only satisfactory treatment is that applicable to the 
disease which produces it. 



ATROPHY OF THE OPTIC NERVE. 

WHAT CAUSES ATROPHY OF THE OPTIC NERVE? 

It may be primary or secondary. 

When primary, it is a part of either locomotor ataxia, 
multiple sclerosis, hemorrhage or alcoholism. 

When secondary, it is a result of optic neuritis. 



DISEASES OF THE CRANIAL NERVES. 137 

WHAT IS THE PATHOI^OGICAI. ANATOMY? 

There is a parencliymatoas degeneration of the nerve, 
with loss of its fibres and an overgrowth of the connective 
tissue of the nerve. 

WHAT ARE THE SYMPTOMS? 

Gradual decrease of vision, color blindness and dilatation 
of the pupil. The ophthalmoscope shows the disc to be of 
a pearly- white color and cup-shaped. The vessels are de- 
creased in size and are fewer in number. 



WHAT IS THE TREATMENT ? 

The treatment is that of the disease which produces it, 
according to the symptoms presented. 



AMBLYOPIA AND AMAUROSIS. 

WHAT ARE THEIR CAUSES ? 

Great shocks to the nervous system, mental anxiety, 
worry, hysteria, concussion of the brain and exhausting 
hemorrhages. There are some drugs which produce these 
conditions, such as quinine, salicylic acid, alcohol and to- 
bacco. Toxic blood-states, such as the consequences of 
uremia, may also cause them. 



WHAT ARE THE SYMPTOMS? 

Dimness of sight or total loss of vision, usually coming 
on suddenly and lasting but a short time. It generally in- 
volves both eyes, but in hysteria it may be greater in one 
than in the other. 

WHAT IS THE PROGNOSIS ? 

Usually good. 



W^HAT IS THE TREATMENT? 

The conditions which produce the blindness should be 
treated. Such remedies as Aurum, Belladonna, Causticum, 
Chelidonium, Phosphorus, Plumbum, Silica and Zincum 
may be indicated. 



138 DISEASES OF THE CRANIAL NERVES. 

HEMIANOPSIA. 

WHAT ARE ITS CAUSES? 

They may be functional or organic. 

Its functional causes are sick-headache, gout and lith- 
emia. 

Its organic causes are tumors of the brain, hemorrhages, 
softening, and inflammations which involve part of the 
optic nerve, the optic tract, or the chiasm. 

The treatment is that suitable for the disease which 
produces it. 



MOTOR NERVES OF THE EYE. 



OPHTHALMOPLEGIA. 

WHAT IS OPHTHALMOPLEGIA ? 

Progressive paralysis of all the muscles of the eye. 

WHAT ARE THE CAUSES OF OPHTHALMOPLEGIA? 

Meningitis of the base of the brain, tumors of the brain, 
injuries, exposure to cold, the poison of diphtheria, hemor- 
rhage into the sheath of the nerve, syphilitic poisoning, 
locomotor ataxia, excessive use of tobacco, excessive expos- 
ure to light, and the use of morphine and alcohol. Rheu- 
matism may also be the cause. 



WHAT ARE THE SYMPTOMS OF PARALYSIS OF THE THIRD 

NERVE ? 

When all the branches of the nerve are paralyzed there 
are ptosis, double vision, and paralytic strabismus; also dila- 
tation of the pupil, which does not contract to light. 

When the branch which supplies the internal rectus 
muscle is paralyzed there is divergent strabismus. 

When the branch which supplies the superior rectus is 
paralyzed there is a deviation of the eye downward, with a 
slight divergence. 

When there is paralysis of the branch supplying the in- 
ferior rectus the eye deviates upward and slightly outward. 



DISEASES OF THE CRANIAL NERVES. 139 

When there is paralysis of the branch supplying the 
inferior oblique there is an inability to move the eye up- 
ward and inward. 

WHAT ARE THE SYMPTOMS OF PARALYSIS OF THE FOURTH 

NERVE? 

There is an inability to move the eye downward and in- 
ward, with convergent strabismus when the patient attempts 
to look downward. 

AVHAT ARE THE SYMPTOMS OF PARALYSIS OF THE SIXTH 

NERVE ? 

There is loss of power in the external rectus muscle, 
which produces a convergent strabismus. Diplopia is a 
common symptom in all forms of strabismus. 



WHAT IS THE TREATMENT OF OPHTHALMOPLEGIA? 

Local. — Electricity applied over the affected muscle is 
often a most useful adjuvant. The faradic current is the 
one most used in these cases, and only the weakest possible 
current should be employed. It may be applied over the 
conjunctiva, which must first be treated by cocaine, or to 
the eyelid in the region of the affected muscle. One pole 
should be placed over the nape of the neck and the other 
near the muscle to be faradized. It makes no difference 
which pole is used over the muscle. Surgical measures 
sometimes have to be employed, as severing some of the 
fibres of the opposite muscle, which may allow the eye to go 
back into place. 

Remedial. — Alumina. — Strabismus due to weakness of 
the internal rectus muscle. 

Gelsemium. — Paralysis of the third and sixth nerves; 
double vision controlled by strength of will ; diplopia due 
to pregnancy. 

Other remedies must be selected according to the totality 
of the symptoms produced by the cause of the trouble. 



INSUFFICIENCIES OF OCULAR MUSCLES. 

WHAT IS MEANT BY INSUFFICIENCES OF OCULAR MUSCLES? 

An inability of the muscles of the eye to maintain their 
equilibrium, whereby the visual axis is kept parallel without 
an effort. 



140 DISEASES OF THE CRANIAL NERVES. 

WHAT ARE ITS CAUSES ? 

It is usually congenital^ or may be present in neuras- 
thenic persons. 

WHAT ARE THE SYMPT03IS? 

A deviation of the visual axis outward, inward or up- 
ward. The result of the strain of the ocular muscles may 
produce headache, nausea, vomiting, epilepsy, chorea, and 
even insanity. 

WHAT IS THE TREATMENT ? 

Local. — Surgery in extreme cases. Prismatic glasses to 
enable the muscles to overcome the insufficiency. 



IRRITATION OF THE OCULAR NERVES. 

WHAT ARE THE CAUSES OF IRRITATION OF THE OCULAR 

NERVES ? 

The first stages of any of the diseases which produce 
paralysis of the nerves may cause irritation; also reflex con- 
ditions, such as worms in children and hysterical patients. 



WHAT ARE THE SYMPTOMS? 

Spasm of the muscles which the nerves supply. The 
spasmodic form of strabismus is a most common symptom. 
The strabismus when due to spasm is the opposite of that pro- 
duced by paralysis; for instance, spasm of the external rec- 
tus would produce a divergent strabismus; paralysis of the 
external rectus Avould produce convergent strabismus. Nys- 
tagmus is often a symptom, and, also, conjugated deviation 
of the head and eyes. The deviation of the head is due to 
the efforts of the patient to overcome the effects of the 
strabismus. 

WHAT IS THE TREATMENT? 

Surgical. — Severing the fibres of the muscle affected 
may benefit some cases. 

Remedial. — BeUadonna. — Strabismus due to spasmodic 
action of muscles, or when resulting from brain affections; 
the eye-balls turn convulsively iji a circle. 



DISEASES OF THE CRANIAL NERVES. 141 

Cina. — Strabismus dependent, upon worms; child has a 
pale, sickly look; blue rings around the eyes; pains about 
the umbilicus; frequent urination; boring at the nose. 

Cyclamen. — Convergent strabismus arising from irrita- 
tion produced by worms; convulsions; convergent strabis- 
mus after measles; double vision. 

Hijoscijanms. — Spasmodic action of the internal rectus 
muscle, with diplopia. 



TRIGEMINUS. 

WHAT DISEASES MAY AFFECT THE TRIGEMINUS? 

Paralysis, spasm, anesthesia, paresthesia, trophic disturb- 
ances, neuralgia and tic douloureux. 



PARALYSIS. 

WHAT ARE THE CAUSES OF PARALYSIS OF THE MOTOR BRANCH 
OF THE FIFTH NERVE ? 

Disease within the pons, such as hemorrhage, softening, 
tumors, and sclerosis; disease of the base of the brain, such 
as tumors, meningitis, and caries of the bone; neuritis, 
caused by a syphilitic gout or exposure to cold; injury of 
the trigeminus, due to fracture of the skull and gun-shot 
wounds through the mouth or nasal cavity. 



WHAT ARE THE SYMPTOMS? 

There is paralysis of the temporal, masseter, and pteryg- 
oid muscles which diminishes the power of mastication 
upon the affected side and the ability to move the lower 
jaw toward the healthy side. If the nerve is diseased there 
is also muscular wasting. 



WHAT IS THE TREATMENT? 

When the paralysis is due to injury surgical measures 
may be necessary. If due to an inflammation of the nerve 
remedies which are suitable for the various forms of neu- 
ritis should be administered. Electricity, both galvanic and 
faradic currents, is useful. 



142 DISEASES OF THE CRANIAL NERVES. 

SPASM. 

WHAT ARE THE CAUSES OF SPASM OF THE FIFTH NERVE? 

Spasm due to primary disease of the nerve itself is ex- 
tremely rare^ but it is symptomatic of some general condi- 
tion and may be clonic or tonic. 

Tonic spasm occurs in tetanus, producing trismus or 
lock-jaw, and also in hysteria. 

Clonic spasm is present in general convulsions. 



ANESTHESIA. 

WHAT ARE THE CAUSES OF ANESTHESIA OF THE FIFTH NERVE ? 

It is most commonly found in syphilitic diseases of the 
brain. It may also occur in hysteria with anesthesia of 
other parts of the body, and in organic disease of the nerve 
centres. Degeneration of the nerve, due to a neuritis or in- 
jury which divides the nerve, will produce anesthesia as well 
as motor paralysis. 

PARESTHESIA. 

WHAT ARE THE CAUSES OF PARESTHESIA OF THE FIFTH 

NERVE ? 

It occurs in persons who are extremely nervous or hys- 
terical, and also in those suffering from anemia. It is one 
of the symptoms, too, of neurasthenia. 



WHAT ARE THE SYMPTOMS ? 

A peculiar numbness, tingling, or formication which does 
not amount to pain, and is not exactly of the character of 
anesthesia. It is nearly constant and is extremely annoying. 
It follows the course of the trigeminal nerve. 

The treatment will be given under tic douloureux. 



TROPHIC DISTURBANCES. 

WHAT TROPHIC CHANGES OCCUR FROM DISEASE OF THE FIFTH 

NERVE ? 

The secretions from the mucous membranes, the lachry- 
mal and salivary glands are lessened in paralysis of the fifth 
nerve and are increased by its irritation. Wounds of the 



DISEASES OF THE CRANIAL NERVES. 143 

cheek heal slowly, and there is a tendency toward ulcera- 
tion. Sometimes the teeth become loosened. Inflammation 
of the eye-ball, opacity of the cornea, and corneal ulceration 
are due to the lack of secretion of the lachrymal duct which 
usually washes all foreign substance from the eye. Herpes 
zoster along the course of the nerve has been observed. 
Flushings and pallor of the face, and swellings are also due 
to irritation of these nerves. 



NEURALGIA. 

HOW MANY FORMS OF FACIAL NEURAI.GIA ARE THERE ? 

Two. The symptomatic and the essential, or tic doul- 



oureux. 



WHAT ARE THE CAUSES OF SYMPTOMATIC FACIAI. NEURALGIA ? 

Any conditions which tend to lower the vital energies of 
the patient, such as anemia, over-work, frequent child- 
bearing, lack of proper nutrition, exposure to cold, diseased 
teeth, diseases of the eye and nose, gout, diabetes, syphilis, 
malaria, rheumatism, injury, epilepsy, and neurasthenia. 
Females suffer more frequently than males, and the majority 
of cases occur in the first half of life. The attacks occur 
with greater frequency during the winter and spring. 



WHAT ARE THE SYMPTOMS ? 

Sharp, intense pain along the nerve, with frequent ex- 
acerbations and remissions. It is lancinating in character, 
though it may be dull and heavy at times, and may last for 
days. When the pain is due to anemia it is usually on the 
top of the head. When caused by eye troubles it is over 
the orbits. When caused by decayed teeth it is in the region 
of the teeth, or in the temporal or cervical region. When 
due to gastric disturbances it is between the eyes. 



WHAT IS THE TREATMENT? 

The relief of the condition which produces the neuralg'a 
will stop it. The remedies will be given under tic doul- 
oureux. 



144 DISEASES OF THE CRANIAL NERVES. 

TIC DOULOUREUX, PROSOPALGIA, EPILEPTIFORn 
NEURALGIA, FOTHERGILL»S NEURALGIA. 

WHAT ARE THE CAUSES OF TIC DOULOUROUX? 

It occurs only in adult life, and women are more liable 
to the disease than men. Any influences which impair the 
general health may produce the disease. Over-fatigue, 
either of body or mind, prolonged emotional excitement, 
excessive use of the eyes, errors of refraction, exposure to 
cold, local or general ; carious teeth ; various toxemic influ- 
ences, such as alcoholism, lead poisoning, diabetes, malaria 
and la grippe^ may cause it. 

WHAT IS THE PATHOLOGICAL ANATOMY ? 

A low grade of neuritis has sometimes been found, but 
as a rule the nerve does not show much change. Diseases 
of the brain^ such as tumors, are occasionally present. 



AVHAT ARE THE SYMPTOMS ? 

The pains are of an intense, darting character, which 
usually commence in the upper lip and at the side of the 
nose. If the ophthalmic division of the nerve be affected 
the pain is referred to the supra-orbital region, radiates 
over the front of the head and is sometimes felt in the eye- 
ball itself and also in the eyelid. If the superior maxillary 
division is involved the pain is in the region between the 
orbit and the mouth, and it is then called infra-orbital neu- 
ralgia. The term "epileptiform" is given to some of these 
neuralgias on account of the sudden and intense onset, last- 
ing a short time, and then passing suddenly away to return 
again in a little while. Many trophic disturbances accom- 
pany this form of neuralgia. The pain is made worse by 
eating, talking, protruding the tongue and breathing in 
cold air. It is confined to one side of the head. The pain 
is usually accompanied by lachrymation and fluent discharge 
from the nose, and the expression of the patient is that of 
intense agony. 



WHAT IS THE TREATMENT? 

Local. — Surgical measures are sometimes used, such as 
resection of the nerve; but such a procedure is not usually 



DISEASES OF THE CRANIAL NERVES, 145 

advisable. The removal of the cause should be accomplish, ed 
if possible. Hot applications, especially dry heat, are often 
of great service. 

Remedial. — Aconite. — Neuralgia of the left side ; face red 
and hot; restlessness; anguish; rolling about; screaming; 
numbness; heavy feeling of the whole face; burning and 
numbness of lips and mouth. 

Belladonna. — Violent neuralgia originating in the right 
temple, spreading over the orbit to the right cheek, worse 
from the slightest motion of the jaws, such as chewing, talk- 
ing; pains come suddenly and disappear as suddenly as they 
come. 

Chelidonium. — Supra-orbital neuralgia of the right side; 
eyes water; throbbing pains; shivering; temples tender on 
pressure ; better from cold water, worse from warmth and at 
night in bed ; violent tearing in the right zygoma. 

Cedron. — Chronic, intermittent prosopalgia always coming 
on at 7 or 8 p. m. and lasting two to four hours with spas- 
modic distortion of the muscles corresponding to the affected 
region; pain starts from a carious tooth, and is of an in- 
tense, burning character. 

Cinchona officinalis. — Violent tearing, laming, burning 
pain in the left side of the face every morning; skin sensi- 
tive to the least touch; pains excessive in the supra-orbital 
region. 

KaJmia latlfolia. — Facial neuralgia involving the teeth 
of the upper jaw, not from caries but after exposure to cold; 
pains rending, agonizing or stupefying ; worse by worry or 
mental exertion. 

MezefeiinK — Lightning-like pains extending from the left 
infra-orbital foramen to the temples, corners of the mouth, 
into the cheek and teeth, down the neck into the shoulder, 
with increased lachrymal secretion ; pains come on suddenly 
while talking or eating; injected conjunctiva; great sensi- 
tiveness of the parts to touch. 

Platinum. — Tearing, boring pain in the right side of the 
face near the canthus of the eye, and extending along the 
nasal branch of the nerve; profuse lachrymation and swell- 
ing of face; attack generally comes on at night. 

Gehemiuni. — Facial neuralgia in nervous women; pain 
in right temple gradually growing more severe extend- 



146 DISEASES OF THE CRANIAL NERVES. 

ing into the ear, and spreading to the eye and side of the 
head; sudden darting, acute pains from region of ear and 
side of head to supra-orbital region; jaws affected spasmodi- 
cally. 

Spigelia. — Prosopalgia, mostly left-sided, with tearing, 
shooting, burning into eye, malar bone and teeth, periodical 
from morning to sunset, worse at noon, worse from motion 
or noise, with lachrymation. 



FACIAL NERVES. 

WHAT ABNORMAL CONDITIONS OF THE FACIAL NERVES ARE 

OBSERVED ? 

Irritation, producing over-action or spasm of the mus- 
cles to which the nerve is distributed; or loss of function 
which produces paralysis of the muscles. 



FACIAL SPASn. 

WHAT ARE THE CAUSES OF FACIAL SPASM? 

It may be idiopathic or due to some organic disease. 
Idiopathic spasm occurs after twenty years of age. That 
which succeeds paralysis alone occurs only in childhood. 
Ordinary facial spasm usually begins between forty-five 
and sixty. There may be an inherited neurotic tendency to 
insanity or epilepsy. Women suffer more frequently than 
men. There is usually a neuropathic constitution. Irrita- 
tion of the fifth nerve by disease of the eyes or teeth, may 
by reflex action produce it. Organic diseases, such as 
tumors affecting the nerve nucleus in the pons or in the 
cerebral centres, cause a symptomatic spasm, but not true 
facial spasm. There may be a spasm due to cortical lesions 
of the brain. Shock, injuries or exposure may also pro- 
duce the idiopathic form. 



WHAT ARE THE SYMPTOMS ? 

The spasm, usually comes on gradually, simply a mo- 
mentary contraction of the muscles now and then which 
does not cause the patient much annoyance. The orbicu- 
laris palpebrarum and the zygomatic! muscles are usually 
the first attacked, the eye is half closed, the angle of the 



DISEASES OF THE CRANIAL NERVES. ' 147 

mouth drawn upwards, and the naso-labial furrow is deep- 
ened. The corrugator supercilli are sometimes involved. 
The spasm is clonic in nature and consists of lightning- 
like twitches which last for a second or two,when there is a 
short cessation after which the spasm is renewed. There 
is no pain, and the spasm is made worse by great nervous 
excitement, conversation, mental emotions, and exposure to 
light and cold. The spasm may be confined to one side of 
the face and is usually so confined at first, and then later 
the other side is involved. There is no wasting of muscles 
and no paralysis. 

There are two kinds of facial spasm which are quite 
common, blepharospasm, a tonic spasm of the orbicularis 
palpebrarum, and nictitating spasm, a winking movement 
of the lids. 

WHAT IS THE DIFFERENTIAI. DIAGNOSIS ? 

There is no difiiculty in diagnosing the disease, the only 
difficulty being in determining the cause of the spasm, 
whether due to organic disease of the brain or to causes 
within the nerve itself. If due to brain troubles there are 
usually other symptoms accompanying it. Idiopathic facial 
spasm is chronic, unilateral, and unaccompanied by pain or 
paralysis. 

WHAT IS THE PROGNOSIS ? 

The prognosis is usually unfavorable, as the disease is 
very rarely cured, especially if it has lasted for some time. 
If there be a reflex cause and that cause can be relieved 
the prognosis will be more favorable. 



WHAT IS THE TREATMENT? 



Remedial. — Belladonna. — Spasm of facial muscles; con- 
tinual winking and trembling of eyelids; convulsive move- 
ments of the facial muscles, with distortion of the mouth. 

Such remedies as Agaricus, Aniica, Baryta carbonka, 
Hyoscyamus^ Ignatia, Opium, Pulsatilla^ Sulphur and 
Strychninum will be of the most benefit. 



148 DISEASES OF THE CRANIAL NERVES. 

FACIAL PARALYSIS. 

WHAT ABE THE CAUSES OP FAClAI. PARALYSIS ? 

The nucleus of the nerve within the pons may be dam- 
aged by various focal lesions; the nerve itself may be com- 
pressed at the base of the brain by tumors, or injured by 
meningitis or hemorrhage. Within its canal in the temporal 
bone it may suffer from the various forms of inflammation 
of the ear, and diseases of the ear in children in cases where 
there is caries of the bone and suppuration of the middle 
ear. Fracture of the base of the skull which passes through 
the petrous portion of the temporal bone may cause the 
nerve to be torn or bruised. A blow on the face may also 
cause paralysis. Inflammation of the nerve, due to cold, is 
a common cause. Pressure upon the nerve by sleeping with 
the head upon the hand may induce a true pressure paraly- 
sis; also the pressure of forceps upon the side of the face 
during delivery. Syphilis is sometimes a cause. Hemorr 
rhage into the nerve sheath often produces it, and it has 
also been observed in rare cases of tabes. 



WHAT IS ITS PATHOLOGICAL ANATOMY ? 

When the disease is due to a peripheral neuritis inflam- 
mation attacks most of the peripheral filaments of the nerve, 
though sometimes the inflammation may be more central. 
When the disease is due to organic lesions within the brain 
the pathology is, of course, characteristic of these conditions. 



WHAT ARE THE SYMPTOMS ? 

The disease may come on suddenly or gradually, accord- 
ing to the conditions which produce it. When due to a neu- 
ritis caused by exposure to cold it will come on suddenly; 
but where pressure from tumors is the cause it will come 
on more gradually. In meningitis we would expect a sud- 
den onset, as well as in fracture of the skull. The paralyzed 
side is smooth, flaccid, and without expression ; the patient 
cannot completely shut the eyes, and when attempting to 
chew upon the affected side the food goes in between the 
cheek and teeth and he is unable to get it out. As the con- 
junctiva is not properly protected from dust and other for- 



DISEASES OF THE CRANIAL NERVES. 149 

eign bodies floating in the air it becomes inflamed and ex- 
tremely painful. The mouth is drawn at first toward the 
sound side. When the patient laughs this drawing of the 
mouth is most noticeable. If the patient is asked to close 
his eyes tightly the eye of the palsied side is not closed, but 
the eye-ball turns up, showing the sclerotic. The nostrils 
of the affected side do not expand during inspiration, saliva 
dribbles from the paralyzed side and the patient cannot 
pucker the mouth in whistling. Taste is lost in the anterior 
part of the tongue on the affected side. After a time there 
is wasting of the muscles of the face to a slight degree ; re- 
actions of degeneration are usually observed. 



WHAT IS THE DIFFERENTIAI. DIAGNOSIS ? 

We have to determine whether the paralysis be due to a 
lesion within the cerebrum, within the pons, at the base of 
£he braia, or whether it be peripheral. If the cerebrum be 
affected the upper branch of the nerve is usually not much 
affected and the patient can close the eye. Disease involv- 
ing the nuclei within the pons is rare and usually involves 
other cranial nerves. When due to lesions at the base of 
the brain there. are usually brain, symptoms which help to 
differentiate it. When the disease is at the base it is usually 
either syphilitic or tubercular. 



WHAT IS THE PROGNOSIS? 

When due to a peripheral neuritis it is generally good, 
although complete recovery does not take place. The dis- 
ease may last for from three to five months ; sometimes cases 
get well within a few weeks. If normal electrical irritability 
begins to return after a few weeks the prognosis is good. 



WHAT IS THE TREATMENT ? 

Local. — Electricity ; the galvanic current after about two 
weeks, just strong enough to produce muscular contractions 
for about five minutes every other day, the negative pole 
being placed over the muscle to be treated. 

Remedial. — Aconite. — When due to exposure to cold 
winds, especially at the very beginning of the disease. 



150 DISEASES OF THE CRANIAL NERVES. 

Belladonna. — In paralysis of the right side of the face; 
face flushed and hot; patient irritable; sleepless and worried. 

Causticum. — Paralysis of the face from taking cold; 
right-sided. 

Other remedies such as Cocculus^ Grraphites^ Kali muri- 
aticurn^ Nux vomica, Rhus toxicodendron^ and Stramonium 
may be given according to general symptoms that may arise 
at the time of the attack. 



AUDITORY. 

WHAT DISTURBANCES OF THE AUDITORY NERVE OCCUR ? 

Diminished function producing deafness; increased ac- 
tion, causing auditory hyperesthesia or hyperacusis ; and irri- 
tation of the nerve, causing tinnitus aurium. 



NERVE DEAFNESS. 

WHAT ARE THE CAUSES OF NERVE DEAFNESS ? 

It may be congenital, as in a very large number of deaf- 
mutes, or it may be the result of the disease in early life. 
Heredity is sometimes a cause, especially when there have 
been marriages with near relations; also disease of the lab- 
yrinth, such as acute or chronic inflammation, syphilitic dis- 
ease, degenerative processes, hemorrhages, and calcareous for- 
mations. Loud noises may produce permanent deafness ; as 
may occasionally diseases at the base of the brain, such as 
meningitis, morbid growths or syphilitic diseases; morbid 
conditions of the nerve itself, such as tumors and interstitial 
hemorrhage; primary degeneration, as in locomotor ataxia; 
softening within the pons affecting the nuclei; tumor of 
the corpora quadrigemina, and diseases of the temporo- 
sphenoidal lobe. Deafness is of functional origin in hys- 
teria, and also occurs as a result of severe hemorrhage. 



WHAT ARE THE SYMPTOMS? 

The main symptom is loss of hearing, which may be 
accompanied by vertigo and tinnitus. In a case of nerve 
deafness the vibrations of the tuning-fork cannot be heard 
when the handle of the fork is placed in contact with the 
skull oyer the mastoid process, but can be heard when held 



DISEASES OF THE CRANIAL NERVES, 151 

close to the external auditory meatus. If the deafness be 
due to a disease*^of the middle ear, or to some obstruction in 
the meatus, the vibrations cannot be heard when the tun- 
ing-fork is held opposite the meatus but can be heard when 
the handle is brought in contact with the skull. The tin- 
nitus is a most constant symptom in these cases and it 
seems to the patient as if it would drive him crazy, being 
often very severe and intense. Nerve deafness may be 
either unilateral or bilateral. 



WHAT IS THE DIFFERENTIAt. DIAGNOSIS ? 

The only disease from which this would have to be dif- 
ferentiated is when deafness is caused by disease of the 
middle ear, or by an obstruction of the external auditory 
meatus. In nerve deafness the vibrations of the tuning- 
fork are heard most plainly when the fork is held opposite 
the meatus. When due to middle-ear disease the vibrations 
of the tuning-fork are heard most plainly when it is in 
contact with the skull. 



WHAT IS THE TREATMENT ? 



Remedial. — Calcarea carhonica. — Ringing, buzzing, 
singing and hissing, or thundering in the ears; deafness with 
feeling as if something lay in front of the membrana tym- 
pani; deafness after use of quinine; right-sided deafness in 
scrofulous subjects. 

China. — Ticking sound in the ear as of a distant watch; 
hardness of hearing with humming or roaring in the ears; 
something seems to be constantly before the ear. 

Mangamim. — Deafness as if ears were stopped, better 
by blowirfg nose, worse during cold and rainy weather; 
fullness of ears with difficult hearing and cracking when 
blowing nose or swallowing. 

Phosphorus. — Difficult hearing, especially of human 
voice; ticking of watch only heard when held close to the 
ear; a sound as of the roaring of rushing waters; sensation 
as if foreign body were lodged in the ears. 

Platinum. — Nervous deafness; great variety of noises in 
the ears; reports in right ear like distant thunder; ringing. 



152 DISEASES OF THE CRANIAL NERVES. 

roaring or rumbling sound in the ears; sensation of cold- 
ness in the ears. 

Silica. — Deafness of nervous origin; comes on suddenly 
after a faint ringing in the ears, and deafness with paral- 
ysis; inflammation of the labyrinth after cerebro-spinal 
meningitis. 

AUDITORY HYPERESTHESIA. 

WHAT ARE THE CAUSES OF AUDITORY HYPERESTHESIA ? 

It occurs most frequently as a symptom in hysteria, 
with acuteness of other senses. It is a common symptom 
in acute cerebral and general diseases. 



TINNITUS AURIUn. 

WHAT ARE THE CAUSES OF TINNITUS AURIUM ? 

Conditions which lead to disease of the labyrinth, of 
which gout is frequent. Neuropathic constitutions, suffer- 
ers from neuralgia and periodical headaches often have this 
symptom. Accumulation of cerumen, growths in the ex- 
ternal meatus, inflammation of the, middle ear, congestion, 
causing increased pressure within the labyrinth, irritation 
of the nerve endings, pachymeningitis, sunstroke, alcohol- 
ism, thickened arteries in old people with imperfect brain 
nutrition may produce the condition. Neurasthenic states 
and reflex irritations are other causes. 



WHAT ARE THE SYMPTOMS? 

Roaring, hissing, buzzing, ringing, singing, whistling, 
or thundering sounds, which seem to be in the head. The 
sound is usually heard in one ear but may be in both. There 
is no cessation of these sounds, and the patient becomes worn 
and weary. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

The symptom itself is easily discerned, but the principal 
point is to discover its cause. The ear should be most care- 
fully examined, both as to the function of hearing and its 
general condition, to determine whether an obstruction is in 
the ear which would produce the symptom, or if it be due 
to some disease within the labyrinth or the brain. 



DISEASES OF THE CRANIAL NERVES. 153 

If the abnormal sound seems to originate in the head, 
and is not complicated by deafness, it is probably of central 
origin. 

Musical sounds are also of central origin. Roaring, pul- 
sating sounds are due to congestion or hemorrhage in 
the labyrinth. Gurgling, bubbling, and boiling sounds are 
usually due to disease of the middle ear with exudation or 
catarrh of the Eustachian tube. 



WHAT IS THE TREATMENT ? 

General. — See that the ear is thoroughly cleansed of 
any accumulation of cerumen, pus or blood that may per- 
haps cause the abnormal sounds. 

Remedial. Amhra grisea. — Roaring, whistling in the 
ears in the afternoon. 

Belladonna. — Roaring, tingling, humming and murmur- 
ing in the ears; extreme sensibility of hearing. 

CJielidonium. — Sensation of wind rushing out of ears; 
loud roaring in ears as of a distant storm; ringing in left 
ear while walking; humming in ears. 

Elaps. — Illusions of hearing; hears whistles and ring- 
ing; continued buzzing as if a fly was enclosed in auditory 
meatus. 

Graphites. — Violent nocturnal roaring; ears feel stuffed 
at times; thundering, roaring sound before the ears; sound 
like air passing into the ears ; hissing sound. 

Nux i^om?C(7.~ Humming, ringing, hissing, roaring, 
whistling; a whirring noise like that of a mill. 

Thuja. — Noise in ears as from boiling water. 



GLOSSO=PHARYNQEAL. 

WHAT AFFECTIONS OF THE GLOSSO-PHARYNGEAL NERVES ARE 

THERE ? 

As the function of this nerve is not fully understood, 
and as its nucleus of origin is so closely associated with 
those of the pneumogastric and spinal accessory nerves, and 
as it has extensive communication with the fifth and seventh 
nerves, and, too, as the nerve is rarely affected alone, it is 
impossible to say what symptoms might occur from disease 
of this nerve. 



154 DISEASES OF THE CEANIAL NERVES. 

PNEUnOGASTRIC. 

WHAT DISEASES MAY AFFECT THE PNEUMOGASTKIC NERVE ? 

Its nuclei may be affected by softening, hemorrhages or 
degeneration. The nerve, as it emerges from the medulla, 
may be compressed by tumors, thickened membranes, or 
aneurisms of the vertebral artery. The trunk of the nerve 
may be injured by gunshot wounds, or by incised or lacerated 
wounds. It may be also damaged in surgical operations by 
being tied with the carotid, or divided in the removal of 
tumors. Neuritis following diphtheria is another condition. 



WHAT ARE THE SYMPTOMS OF I.ESIONS OF THE PNEUMOGAS- 

TRIC NERVE? 

They are of two kinds: Spasm and paralysis. 

Spasm due to the irritation of the nerve causes laryn- 
geal spasm, vomiting, and depression of the heart's action. 

In paralysis there is increased frequency of the heart's 
action, diminished frequency of respiration, and Cheyne- 
Stokes breathing, 

PHARYNGEAL BRANCHES. 

WHAT ARE THE SYMPTOMS OF DISEASE OF THE PHARYNGEAI. 

BRANCHES? 

Paralysis of the Pharynx. — Manifested by difficulty of 
swallowing. Food lodges in the pharynx instead of passing 
into the esophagus. Small particles of liquid sometimes 
enter the larynx and produce spasm and choking. Liquids 
may pass into the nose. Food made into a pulp is swal- 
lowed better than solids. 

Spasm of the Pharynx. — A functional disturbance, often 
due to hysteria producing the so-called "globus hystericus." 



LARYNGEAL BRANCHES. 

WHAT ARE THE SYMPTOMS OF DISEASE OF THE LARYNGEAL 

BRANCHES ? 

The larynx receives sensory fibres from the pneumogas- 
tric and motor fibres from the accessory portion of the 
spinal accessory. The branches supphang the muscles of 
the larynx are the superior laryngeal, which supplies the 



DISEASES OF THE CRANIAL NERVES. 155 

crico- thyroid muscle and the epiglottis, and the inferior 
laryngeal, which supplies all the other muscles of the larynx. 
Disease of one or the other of these branches manifests dif- 
ferent phenomena. The vocal cords are abducted and the 
glottis opened mainly by the posterior-cricoid muscles. 
They are adducted and the glottis closed by a number of 
muscles, but mainly the crico-arytenoid. 

Paralysis of the Laryngeal Muscles. — This produces 
alteration or loss of voice, derangement of the regulation of 
the entrance of air during respiration, and defective move- 
ments of the vocal chords. 

Spasm of the Larynx. — Commonly affects children, and 
may be accompanied by difficult breathing and cyanosis. 
It is usually nocturnal. 

It is often called spasmodic croup, or laryngismus strid- 
ulus. . 

PULHONARY BRANCHES. 

WHAT ARE THE SYMPTOMS OF DISEASE OF THE PULMONARY 

BRANCHES ? 

The muscular fibres of the bronchi are supplied by the 
pneumogastric. Spasmodic contractions of these fibres pro- 
duce asthma; there is now no doubt but that the majority 
of cases of asthma are due to some irritation of the pul- 
monary branches of the pneumogastric. 



CARDIAC BRANCHES. 

WHAT ARE THE SYMPTOMS OF DISEASE OF THE CARDIAC 

BRANCHES? 

These branches regulate the action of the heart by in- 
hibition, and any irritation of them would produce a slow- 
ing of the heart's action. This sometimes occurs in 
meningitis and in rapid compression of the brain. Excessive 
rapidity of the heart's action is produced by paralysis of the 
cardiac branches, and has been observed in diphtheritic 
neuritis and as the result of injury of the nerve. Persons 
suffering from sexual neurasthenia may be troubled with 
irregular heart's action, due to disturbances of nutrition of 
the pneumogastric. Angina pectoris is caused by irritation 
of these branches. 



156 DISEASES OF THE CRANIAL NERVES. 

ESOPHAGEAL AND GASTRIC BRANCHES. 

WHAT ARE THE SYMPTOMS DUE TO DISEASE OF THESE 

BRANCHES? 

These brandies are not often disturbed in function. 
Vomiting may result either from reflex stimulation of the 
gastric branches, or by direct irritation of the pneumogas- 
tric. Gastralgia is sometimes due to irritation of these 
branches. The gastric crises which occur in locomotor 
ataxia are undoubtedly due to irritation affecting the nuclei 
of the pneumogastric. 

WHAT IS THE DIFFERENTIAI. DIAGNOSIS? 

The main symptoms diagnostic of disturbances of the 
pneumogastric are laryngeal paralysis, retarded respiration, 
accelerated heart's action and vomiting. The seat of the 
lesion can be determined only by the distribution of the 
symptoms. 

If one vocal cord be paralyzed it would indicate pressure 
upon one inferior laryngeal, or upon the spinal accessory at 
the medulla. 

Bilateral paralysis of the larynx would denote a lesion 
within the medulla. 

WHAT IS THE PROGNOSIS ? 

This depends entirely upon the nature of the disease that 
is producing the trouble. 



WHAT IS THE TREATMENT FOR THESE CONDITIONS? 

GrENERAL. — In pharyngeal or laryngeal paralysis, also in 
spasm of the pharynx and larynx, rest of the muscles is the 
most important consideration. In irritation of the cardiac and 
gastric branches attention to diet will often very largely 
remedy the difficulty. But for any of the lesions, whether 
they be organic or functional, homeopathic remedies will be 
of inestimable service in alleviating the distressing symp- 
toms which are present. 

Remedial. — Aco)ute. — Laryngismus stridulus, after ex- 
posure to dry, cold winds; awaking in first sleep; child in 
agony, impatiently tossing about; loud breathing during 
expiration; larynx sensitive to touch and to expired air as if 



DISEASES OF THE CRANIAL NERVES. 157 

denuded; voice husky, can scarcely speak; hoarseness after 
singing or speaking. 

Causticum.—Aiph.oma, with rawness and tickling in the 
throat; dry cough; pain in the throat; must swallow con- 
tinually ; feels as if the throat were too narrow ; paralysis of 
the esophagus; mucus collects in the throat and can not be 
raised by hawking. 

Gelsemiiim. — Painful sensation of a lump in the esoph- 
agus that cannot be swallowed, in hysterical women; 
spasmodic sensations and cramp-like feeling in the gullet; 
paralytic dysphagia; inability to swallow or speak; spas- 
modic affections of the throat; nervous aphonia with dry- 
ness and burning in the throat; laryngismus stridulus. 

Ipecac. — Spasm of cords; constant alternate contraction 
and relaxation of cords following each other in rapid suc- 
cession ; spasm of glotitis ; blueness of face and coldness of ex- 
tremities; rattling noises in a,ir-passages during respiration; 
voice hollow. 

Phosphoims. — Irritable acute weakness of vocal organs; 
cannot talk on account of pain in the larynx ; laryngeal 
croup; aphonia; rapid sinking; rapid respiration; suffocative 
pressure in the upper part of the chest: larynx sensitive. 

Bhus toxicodendron. — Hoarseness with roughness, scrap- 
ing, or raw sensation in the larnyx from over-straining the 
voice; muscular exhaustion of larynx from loud and pro- 
longed exercise of the voice; throat feels sore and stiff after 
straining it. 

Sambiicus. — Spasm of glottis; breathing is of a wheez- 
ing, crowing character, worse after midnight and from lying 
with head low; breathing anxious^ loud and quick; child sud- 
denly awakes nearly suffocated, sits up in bed, turns blue, 
gasps for breath, which he finally gets, spell passes off, and 
the child lies down again, to be aroused sooner or later in the 
same manner. 

Spongia. — Great dryness of larynx ; talking, singing or 
swallowing hurts larynx ; starts suddenly from sleep with 
contraction of larynx; paroxysms of dyspnea and cough; 
constriction and suffocation during sleep ; sawing respira- 
tion. 



158 DISEASES OF THE CEANIAL NEEVES. 

SPINAL ACCESSORY. 

EXTERNAL PART. 

This is really a spinal nerve and supplies the sterno- 
cleido-mastoid and trapezius muscles. It is purely motor 
and its diseases are characterized by paralysis or spasm. 



WHAT ARE THE CAUSES OF DISEASES OF THE SPINAL ACCES- 
SORY NERVE? 

The nuclear cells are sometimes degenerat,ed in progres- 
sive muscular atrophy, and in polio-myelitis-anterior. Exu- 
dation in meningitis, intra-cranial tumors or enlarged glands 
may compress the nerve in its course and cause various 
symptoms. In fractures of the skull and in diseases of the 
vertebrae the nerve is sometimes injured. 



WHAT ARE THE SYMPTOMS? 

Paralysis of the sterno-cleido-mastoid and trapezius 
results from degeneration or disintegration of the nerve. 
In paralysis of the sterno-cleido-mastoid there is an inability 
to rotate the head to the opposite side. In paralysis of the 
trapezius the power of supporting the head in the upright 
position is impaired, especially if the paralysis be bilateral, 
and it readily falls forward so that the chin rests upon the 
sternum. When both sterno-mastoids are paralyzed there 
is a tendency for the head to fall backward. The trapezius 
is never completely paralyzed from disease of the spinal 
accessory, as this nerve only supplies the upper portion of 
the muscle. In paralysis of the upper portion there is altera- 
tion in the contour of the outer side of the neck. It as- 
sumes a concave curve instead of a nearly straight line, as 
in the normal condition. In paralysis of the middle portion 
of the trapezius there is a slight drooping of the shoulders, 
the scapula recedes from the spine and the lower angle is 
rotated inwards on account of the unopposed action of the 
rhomboideus and the levator anguli scapulae. Elevation of 
the arm is also somewhat impaired. 



W^H AT IS THE TREATMENT ? 



General. — Electricity and massage are of benefit in 
these cases. 



DISEASES OF THE CRANIAL NERVES. 159 

HYPOGLOSSAL. 

WHAT DISTURBANCES OF THE HYPOGLOSSAL OCCUR? 

Paralysis, spasm and hemiatrophy. Paralysis is caused 
by degeneration of the nuclei, and forms a part of bulbar 
paralysis. The root fibres are sometimes damaged by soften- 
ing or tumor within the medulla, and outside of the pons 
the fibres of origin are damaged by meningitis and various 
growths. 

WHAT ARE THE SYMPTOMS OF PARALYSIS OF THE HYPO- 
GLOSSAL NERVE? 

If one nerve only be affected the tongue deviates toward 
the affected side. In bilateral paralysis the tongue lies mo- 
tionless within the mouth, articulation is impaired and mas- 
tication is hindered because the tongue is not able to keep 
the food between the teeth. There is also wasting of the 
tongue when the nucleus of the nerve is diseased. Neither 
sensation nor taste is impaired. 



WHAT ARE THE SYMPTOMS OF SPASM OF THE HYPOGLOSSAL 

NERVE ? 

There are stuttering and stammering on attempting to 
speak. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

There is no difficulty in differentiating this disease, as 
the paralysis and hemiatrophy, if incomplete, the affection 
of one nerve, and paralysis of the whole tongue, which is 
usually a part of bulbar paralysis, are all easily determined. 



AVHAT IS THE PROGNOSIS? 



The paralysis depends entirely upon the causing lesion. 
The spasm is usually improved after a time. 



WHAT IS THE TREATMENT? 

In paralysis of the hypoglossal the treatment is the same 
as in bulbar paralysis. The spasm is often treated by edu- 
cational methods, as teaching the patient to control the 
action of the tongue as much as possible. 



PART V. 

DISEASES OF THE SPINAL CORD AND ITS 

MEMBRANES. 



SPINAL riENINQITIS. 

WHAT IS SPINAL MENINGITIS? 

It is an inflammation of the membranes of the spinal 
cord. It may be acute or chronic. 



INTO WHAT TWO FORMS IS SPINAL MENINGITIS DIVIDED IN 
REGARD TO THE DURA MATER? 

External meningitis, which begins outside of the dura 
mater, and internal meningitis, which begins within the 
dura mater. 

EXTERNAL SPINAL MENINGITIS. 

WHAT IS EXTERNAL, SPINAL MENINGITIS ? 

It is an inflammation of the outer surface of the dura 
mater, sometimes called external pachymeningitis, or peri- 
pachymeningitis. 

WHAT ARE THE CAUSES OF EXTERNAL SPINAL MENINGITIS ? 

It is generally due to extension of some contiguous dis- 
ease, such as caries of the bones of the spine, syphilitic 
disease of the vertebrae, deep sacral bed-sores, ascending 
neuritis, psoas abscess, retro-pharyngeal abscess, and frac- 
tures of the spinal column. 



WHAT IS THE PATHOLOGICAL ANATOMY? 

The inflammation may be simple or purulent. If sim- 
ple the dura mater is only reddened and slightly opaque, 

* (160) 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 161 

with a small amount of lymph upon its surface. When 
purulent it is covered by a layer of pus; the fat outside 
the dura mater b'ecomes quickly absorbed, and the mem- 
branes after a time are adherent to the bone. 



WHAT ARE THE SYMPTOBIS ? 

These are often complicated by those of the primary 
disease. They consist mainly of symptoms of irritation of 
motor and sensory roots, followed by symptoms of com- 
pression of these and of the spinal cord, pain in the back, 
in the region of the loins, which is increased by movement, 
stiffness of the muscles of the spine, and hyperesthesia of 
the skin. The rigidity of the muscles of the back is some- 
times followed by paralysis, and the hyperesthesia is fol- 
lowed by anesthesia. There is also loss of reflex action of 
the paralyzed muscles, with flaccidity of the muscles. 
There is generally paralysis of the sphincters. Trophic 
disturbances manifest themselves by bed-sores and lividity 
of the skin. There are radiating pains extending down 
the limbs, w^ith twitching, followed by paresis of the lower 
extremities, which goes on to paraplegia. There is also a 
bending backward of the trunk upon the hips. 



WHAT IS THE DIFFERENTIAI. DIAGNOSIS ? 

The diagnosis is made upon the presence of a primary 
disease followed by the symptoms just enumerated. 



WHAT IS THE PROGNOSIS ? 



It is usually grave, because the cause of the trouble is 
generally a serious one. 



WHAT IS THE TREATMENT ? 



GrENERAL. — In caries of the bone, in which there is an- 
gular curvature of the spine, the treatment for Pott's dis- 
ease W'ill be of benefit. 

The remedies for this disease will be given under inter- 
nal spinal meningitis. 



162 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

ACUTE INTERNAL SPINAL MENINGITIS. 

WHAT IS ACUTE INTERNAL SPINAIi MENINGITIS? 

It is an inflammation of tlie inner surface of the dura 
mater, the arachnoid, and the pia mater. 



WHAT ARE ITS CAUSES ? 

Local, such as injuries to the spine, fracture or disloca- 
tion, concussion, puncture of a spina bifida, exposure of the 
back to cold, extension of adjacent inflammation, inflam- 
mation due to morbid blood states, such as septicemia, or the 
virus which produces cerebro-spinal meningitis, tuberculo- 
sis, syphilis, typhoid fever, exposure to cold and also isola- 
tion. 

WHAT IS THE PATHOI.OGICAI. ANATOMY? 

The inflammation may be simple or purulent. It is usu- 
ally wide in extent. It may be localized at certain levels. 
The spinal fluid is generally increased in amount. If the dis- 
ease lasts for some time the pus becomes absorbed in a meas- 
ure, the connective tissue is increased, and the dura, arach- 
noid and pia are bound to the cord! The roots of the spinal 
nerves are compressed by the inflammatory product which 
surrounds them. In tubercular meningitis the exudation is 
of a fibrinous character and tubercular granules are found on 
the pia mater, arachnoid, and on the inner surface of the 
dura mater. 

WHAT ARE THE SYMPTOMS? 

The first symptoms may be a slight pain in the back and 
general prostration, which are followed by a chill, fever and 
severe pains in the back, varying according to the locality of 
the inflammation; they may be felt along the whole length 
of the spine. 

Pain. — Pain, due to irritation of the nerve roots, is ec- 
centric, that is, radiating from the centre to the periphery, 
extending down the upper and lower extremities and around 
the trunk, comes in paroxysms and is intense. It is sharp, 
darting, burning, or constricting. There is usually con- 
stant pain, which is increased at times by movement or by 
pressure. 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 163 

Muscular Spasm. — Rigidity o£ the muscles of the back 
usually accooipanies the pain. It first manifests itself in 
the neck, as that is the most mobile part, the head is drawn 
backward and there is also slight stiffness of the neck. Some- 
times spasm is so severe that there is complete opisthotonos, 
such as that which occurs in tetanus. 

Hyperesthesia of the Cutaneous Surface. — This is some- 
times extreme, and the least movement or pressure of the 
limbs, particularly the legs, will cause great pain. 

iJyspnea. — Oppression of the breathing is present when 
there is severe spasm of the thoracic muscles. 

Pulse. — This may be frequent or slow. 

Temperature. — The body heat if raised will be raised 
only a degree or two. 

"Headache., Delirium and Coma. — These symptoms occur 
when the inflammation has extended to the membranes of 
the brain. If the Cheyne-Stokes respiration be present it 
will show that the medulla has become involved. As the 
disease progresses the symptoms of hyperesthesia and spasm 
give place to those of anesthesia and paralysis. Reflex ac- 
tion disappears. In a fatal termination there is sometimes 
considerable rise in temperature. 



WHAT IS THE DIFFERENTIAL, DIAGNOSIS ? 

The pain in the back, rigidity of the neck and spine, 
hyperesthesia and spasm of the limbs, which are made worse 
upon attempting to move them at the beginning of the dis- 
ease, associated with fever, are characteristic symptoms. The 
only difficulty in the diagnosing of the acute form of the 
trouble is when it runs an almost latent course and there is 
but little tendency to invade the nerve structures. 

From myelitis it is differentiated by the severe pain 
which is not present in myelitis. In myelitis the paralysis 
comes on early. 

From tetanus it is differentiated by the fever at the onset 
in meningitis. 

WHAT IS THE PROGNOSIS? 

It is grave in all cases. The greater the severity of the 
acute symptoms, and the earlier the symptoms of irritation 
give way to those of paralysis, the more serious is the prog- 



164 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

nosis. The disease may terminate in a day or two, or it may 
last for two or three weeks and then end in death or possibly 
in recovery. Homeopathic treatment does more to change an 
unfavorable prognosis than anything else, extremely serious 
cases very frequently recovering under this method of treat- 
ment. 

WHAT IS THE TREATMENT? 

GrENERAL. — Perfect rest and quiet are absolutely import- 
ant throughout the whole course of the disease. Light and 
sound should be excluded from the room as much as possible, 
and all bodily and mental exertion avoided. Spinal ice-bags 
are sometimes of use. Occasionally the patient may find re- 
lief from some of his symptoms for a little while by lying in 
the prone position, but the muscular exertion which is neces- 
sary to get into the position may do more harm than good. 

Dietetic. — Nourishment should be given frequently and 
in small quantities. Milk, flour gruel, corn-meal gruel, and 
beef juice if there is not much fever, are tlie main articles of 
diet. Oat-meal or rice boiled for several hours may be given 
hot or cold, as the patient desires. The patient may have as 
large quantities of water as he wishes, but not too near the 
times of taking food. In cases that go on to recovery milk 
toast, blanc mange, plain custard, farina, eggs and wine jelly 
may be given. 

Remedial. — Aconite. — After exposure to cold; stiffness 
of the back; burning, shooting pains in the spine; numb- 
ness in the small of the back extending into lower limbs; 
shooting, tearing pains in legs; legs almost powerless; after 
sitting, numbness; excessive restlessness and tossing about. 

Belladonna. — Burning, throbbing pain in the spine; back 
aches as if it would break ; cramp-like sensation in the lum- 
bar region; convulsive movements of the limbs; frequent 
startings as if electric shocks were running through the 
limbs. 

Bryonia. — Painful stiffness of the back, worse upon the 
slightest motion ; pain extends through the thorax and lower 
portion of the sternum. 

Cicuta. — Pain in nape of neck; spasmodic drawing of 
head backwards, with tremor of the hand; back bent back- 
wards like an arch ; complete powerlessness of limbs after 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 105 

spasmodic jerks ; spasmodic contortions and fearful jerking 
of limbs; trembling of upper and lower limbs. 

Coccidus. — Stiffness of the cervical muscles and great 
weakness; constant pain in the back shooting through the 
body on both sides and along the spine to the occiput; tender- 
ness on pressure upon the vertebral spines ; trembling in the 
back ; numbness and paralytic feeling in the arms ; paralytic 
rigidity of extremities. 

Hypericum. — After a fall; slightest motion of arms or 
legs extorts cries; cervical vertebra very sensitive to touch; 
consequences of spinal concussion; lies on back, jerking 
head backwards ; crawling in hands and feet as if they were 
numb. 

Mercurius. — Violent pains in the spine, worse from mo- 
tion; involuntary jerking in the limbs; tearing and stitch- 
ing in the lower limbs at night and during motion, with 
sensation of coldness; paralysis of lower extremities, bladder 
and rectum. 

CHRONIC INTERNAL SPINAL riENINQITIS. 

WHAT ARE THE CAUSES OF CHRONIC INTERNAL SPINAI. MEN- 
INGITIS ? 

This is a rare disease, occurring most frequently in 
adults, and in men more frequently than in women. 
Exhausting and debilitating influences predispose to the 
disease; also severe and prolonged over-exertion. Repeated 
exposure to cold, trauma, and the results of concussion are 
sometimes causes. Syphilis, chronic alcoholisui and tuber- 
culosis are other causes. 



AVHAT IS THE PATHOLOGICAL ANATOMY? 

There is an increase of connective tissue cells, thickening 
and opacity of the membranes. There is also inflammation 
of the nerve roots, and sometimes the spinal cord itself may 
be involved, producing what is called a meningo-myelitis. 
Induration of the spinal cord, constituting a peripheral 
sclerosis, is found. 

AVHAT ARE THE SYMPTOMS? 

These, like the symptoms of the acute form, are pro- 
duced by irritation of the membranes and of the spinal 



166 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

nerve roots. They are much the same as those of the acute 
form, but come on more slowly and less severely. Pain 
in the back (which is made worse by movement) of a dull, 
heavy character, with stiffness of the back and tenderness 
along the spine is the most prominent symptom. Eccen- 
tric pains, sharp, severe or rheumatic in character, come in 
paroxysms, but are usually worse at night. Hyperesthesia 
of the skin may exist to a greater or less degree. The pains 
may also extend down the extremities, and after they have 
persisted for months there is a gradually increasing weak- 
ness and wasting of muscles, with the reaction of degeneration 
for a time, but complete loss of electrical irritability later. 
Inco-ordination of the lower extremities is sometimes pres- 
ent. There is paralysis of the sphincters, and bed-sores 
form later. 

WHAT IS THE DIFFEKENTIAI. DIAGNOSIS? 

The pain and stiffness are sometimes taken for spinal ir- 
ritation, but in the latter condition the spine is tender only 
in spots, the pains are not radiating, and there are no symp- 
toms of paralysis. 

In muscular rheumatism there is no tenderness of the 
spinal column and no increased sensitiveness of the cutane- 
ous surfaces. 

In progressive muscular atrophy the wasting is not pre- 
ceded by severe pain as it is in meningitis ; neither is there 
any hyperesthesia or anesthesia. 

In locomotor ataxia there is a greater degree of ataxy 
but no weakness, as in meningitis. 



WHAT IS THE PROGNOSIS? 



As in the acute form, much can be done with homeo- 
pathic remedies. 



WHAT IS THE TREATMENT ? 



General. — Rest is most important. In severe cases it 
is absolutely necessary. Everything must be done to pre- 
vent increase of pain. The prone position can be main- 
tained with better results than in the acute form and is ex:- 
tr-emely helpful in many cases, 



DI.SEASKS OF THE SPINAL CORD AND ITS MEMBRANES. 167 

Dietetic. — ■Good, nourishing food is of the utmost im- 
portance; and almost everything that the patient wishes 
that is not hard to digest can usually be given. 

Remedial.— Ca/car^a carhonica. — Stiffness and rigidity 
at the nape of the neck; pain in the small of the back; can 
scarcely rise from his seat; violent, boring, tearing, burning 
pains extending down the back, with inclination to move 
about; painful stiffness in the back, making change of 
posture very difficult; weakness and lameness of extremities; 
heaviness and painful weight in limbs, with great fatigue 
on walking; sweating of lower extremities. 

Niix vomica. — Backache in lumbar region worse in bed; 
sudden loss of power in legs in the morning; hands and 
feet go to sleep easily; stiffness and tension in hollow of 
knees; numbness and formication along the spine and into 
extremities; ataxic symptoms in meningitis from alcohol- 
ism; incomplete paralysis of upper and lower extremities; 
aching, drawing or bruised pain in the limbs, worse during 
motion and at night. 

Rhus toxicodendron. — Stiffness in small of back^ painful on 
toiotion; while sitting small of back aches, as also after long 
stooping or bending; pain as if bruised in small of back 
whenever he lies quietly upon it or sits still ; sensation as if 
something were grasping the back and as if the flesh had 
been beaten; better when moving slowly about; inflammation 
of the membranes from getting wet or sleeping on damp 
ground; sensation of stiffness on first moving limbs after 
rest. 

Secale cornuttim. — Lassitude, weakness, heaviness, trem- 
bling of limbs; most violent convulsive movements of limbs 
occur several times a day; paraplegia; violent pain in the 
back, especially in sacral region ; anesthesia and paralysis of 
limbs; painful contraction of flexor muscles; paralysis of 
bladder and rectum. 

SPINAL HEnORRHAGE. 

INTO WHAT PART OF THE SPINAL CORD MAY HEMORRHAGE 

TAKE PLACE? 

It may occur outside of the dura mater, between it and 
the bones, when it is called extra-meningeal ; or it may occur 
within the dura mater, being then called intra-meningeal; 



168 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

within the arachnoid, when it is called sub-arachnoid; or 
into the cord itself, hematomyelia. 



WHAT ARE THE CAUSES OF SPINAL HEMORRHAGE? 

It may occur in newly born children or in adults. If in 
a newly born child it is due to rupture of the vessels during 
birth. Immediate causes of hemorrhage are injuries, such as 
fracture of the vertebra, blows or falls on the back, and 
falls on the feet or buttocks. It may take place as a result 
of severe convulsions of epilepsy, eclampsia, tetanus, chorea, 
from strychnia poisoning, and also from severe muscular 
exertion. Some diseases in which there is hemorrhagic 
tendency may induce it, such as purpura, acute specific dis- 
eases, small-pox, yellow fever, etc. 



WHAT IS THE PATHOLOGICAL ANATOMY ? 

Hemorrhage outside of the dura mater comes from the 
large plexus of veins which lie between it and the bone. 
The extravasation may be small or large in extent. The 
blood usually coagulates wholly or partially. 

Hemorrhage within the membranes usually comes from 
the vessels of the pia mater. It may surround the cord for 
a few inches, or it may fill the whole sub-arachnoid cavity. 
The spinal fluid is often blood-stained, and the spinal cord 
is discolored and compressed. 

When with the cord itself there is usually a fatty degen- 
eration of the coats of the vessels. The clot may be absorbed 
and a cavity left in the cord, or it may be the cause of my- 
elitis. 

WHAT ARE THE SYMPTOMS? 

Sudden, burning pain in the back, which corresponds in 
position with the seat of the hemorrhage. This pain is ac- 
companied by pains along the course of the nerves, of a 
darting, burning character, and of great intensity. There 
are also sensations of tingling, numbness and formication, 
accompanied by hyperesthesia. 

Muscular spasm generally accompanies the pain and in- 
volves the vertebral muscles, causing rigidity of the spine, 
or even opisthotonos; it also involves the muscles supplied 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 169 

by the nerves in which the pain is felt, and those muscles 
supplied from the cord below the seat of hemorrhage. 

Later there is weakness or paralysis and anesthesia. 
There may also be spasmodic retention of urine. 

In hemorrhage of the cord the symptoms are those of 
numbness, weakness, sudden paraplegia, with anesthesia and 
paralysis of the sphincters. There is not so much rigidity 
of the muscles as when the meninges alone are affected. In 
spinal hemorrhage the mind is usually clear and the patient 
feels the paralysis and numbness commencing in the ex- 
tremities and gradually extending up the body, involving 
the trunk, intercostal muscles and diaphragm, when death 
take place from suffocation, sometimes within a few hours 
from the onset. 

WHAT IS THE DIFFERENTIAI. DIAGNOSIS ? 

When the above symptoms follow injury of some kind 
the diagnosis is usually plain. 

Meningitis comes on more gradually and has fever at 
first ; while in spinal hemorrhage if there is any fever it 
comes on later. 

WHAT IS THE PROGNOSIS." 

In severe cases death usually takes place in a few hours. 
If the symptoms have reached their height in a few hours 
and then gradually begin to subside the patient may recover, 
if secondary inflammation does not take place. The progf- 
nosis may often be determined by the rapidity of onset. 
Hemorrhage in the upper portion of the cord is extremely 
grave because the respiratory organs may be interfered with. 



WHAT IS THE TREATMENT ? 

General. — Absolute rest is the first thing to be en- 
forced. The patient should lie prone or on one side, not 
on the back. Ice-bags up and down the spine often give 
much relief. 

Remedial. — Aconite. — Numbness of small of back, ex- 
tending into the lower limbs; stiffness of the back; burn- 
ing, shooting pains in the spine; formication in arms, 
hands and fingers; great restlessness and nervous excita- 
bility; tossing about. 



170 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

Arnica. — After injury; violent pains in the spine; ting- 
ling in the back; back painful, as if it had been beaten; 
extremities feel weary, as if bruised by blows; great heavi- 
ness and soreness of limbs; numbness; swelling or tingling 
of the limbs; weakness; weariness; sensation of being 
bruised; bed feels too hard; paralysis of extremities. 

Hamamelis. — Severe pains in hypogastric regions, ex- 
tending down the legs; back feels as if it would break; 
bruised feeling in upper arms and shoulders; stiffness in 
arms and shoulders; great soreness of affected muscles; gen- 
eral lassitude and feeling of weakness. 

Veratriim viride. — Opisthotonos, with great arterial 
excitement; hands and feet cold; shocks in limbs; heat and 
redness down the spine; back of head hot; galvanic shocks 
of great violence in limbs; severe aching of back of neck 
and shoulders. 

MYELITIS. 

WHAT IS MYELITIS, AND WHAT ARE ITS DIFFERENT FORMS ? 

It is an inflammation of the spinal cord. It may be acute, 
subacute, or chronic. Acute myelitis is that form in which 
the symptoms reach their height in less than two weeks. In 
subacute myelitis the symptoms reach their height in from 
two to six weeks. In chronic myelitis the symptoms reach 
their height in a very much longer time than six weeks. 

The inflammation is transverse when the whole thickness 
of the cord is involved in a small vertical extent; when a 
larger area of the cord is inflamed it is called diffuse; when 
a small spot is inflamed it is called focal ; when many small 
spots, either near each other or distant, are inflamed it is 
called disseminated ; when the gray matter around the cen- 
tral canal is involved it is called central myelitis. 

Acute transverse myelitis is the most common form. 



ACUTE TRANSVERSE HYELITIS. 

WHAT ARE ITS CAUSES ? 

It may occur at all ages, and males suffer- more fre- 
quently than females. Injury, such as lacerations, bruises, 
punctured wounds, or concussion (producing the so-called 
''raihvay skin "); violent action of the muscles of the spinal 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 171 

cord, exposure to cold when the body is heated, lying on the 
damp ground or snow, cold bathing, over-exertion, sudden 
suppression of the menses, or other long-continued dis- 
charges; over-action of the cord; toxic blood states, such as 
typhus, typhoid fever, variola, measles and puerperal fever; 
syphilis, alcoholism, inflammation of the uterus, bladder, 
and kidneys ; lead or arsenical poison may be causes. 



WHAT IS THE PATHOLOGIC AIL ANATOMY? 

The cord at the inflamed part appears soft, swollen, 
either red and hyperemic, or pale and anemic. If there be 
extravasation of blood there is a condition called red soften- 
ing, in which the affected part is diffluent, like cream. If the 
effusion has lasted for some time there is a chocolate color 
given to the softened part. After a longer time the blood 
pigment changes and there is a yellow appearance called 
yellow softening. In some cases the destruction of nerve 
elements is very much greater than the extravasation of blood, 
so that we have a condition called white softening. There 
is a degeneration of fibres, granules, myelin, and granule 
corpuscles mixed with numerous red blood discs and leuco- 
cytes and other cell elements in the tissues. Connective 
tissue changes are most noticeable in the white matter. 
The axis-cylinders and myelin sheaths are often very much 
disintegrated. After a few weeks the processes of absorption 
and cicatrization and secondary degeneration occur; and the 
fatty and granular matters and leucocytes disalppear. The 
axis-cylinder, which is usually the lasi destroyed, recuperates 
first; but when the nerve cell is destroyed it never develops 



WHAT ARE THE SYMPTOMS ? 

For some days there may be a general malaise, with 
shivering, headache, depression, loss of appetite, fever, with 
some weakness of the lower extremities, accompanied by 
numbness, tingling or burning sensation, pain in the back 
and limbs, whicb, however, soon ceases; occasionally cramps 
and twitchings of the limbs are present. 

Paralysis. — This generally comes on rapidly, and may 
reach a considerable degree in a few hours. If the patient 
be walking he may suddenly feel his legs becoming very 



172 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

heavy, as if they were made of lead. If he sits down to rest 
awhile and then tries to walk again he finds that he cannot 
stand, and in a few hours is unable to raise his legs. With 
these symptoms there is numbness and tingling of the ex- 
tremities. Sometimes the paralysis comes on during the 
night, the patient going to bed perfectly well and awaken- 
ing with a complete paraplegia; but generally the onset of 
the paralysis occupies several days or a week, or even two 
weeks. When the paralysis has reached its height it is 
usually complete, but it may be incomplete. If it is incom- 
plete in the lower extremities the flexor muscles suffer more 
than the extensors. If the cervical region be inflamed there 
may be paralysis and atrophy of the arms and also of the 
intercostals. An inflammation above this point causes par- 
alysis of the respiratory organs, and death ensues quickly. 

Sensation. — Sensation is lost in severe cases up to the 
level of the lesion. In slight cases only a partial loss is 
noticed. Sometimes there is general hyperesthesia. Sensa- 
tion of a girdle around the body is very distinct, and is due 
to irritation of the nerve roots. Analgesia is sometimes 
present. 

Reflex Action. — This is sometime decreased at the begin- 
ning of the disease, but later becomes excessive. When the 
lesion is in the lumbar region there is diminished reflex 
action and flaccidity of the paralyzed muscles, which waste 
and show reaction of degeneration. If the dorsal region is 
affected reflexes are present and after a while become exag- 
gerated. 

The Sphincters. — They are early affected. For a short 
time there is retention of urine, and later there is inconti- 
nence. If the lumbar region be affected there is inconti- 
nence from the beginning. 

Cystitis. — Cystitis is due to the inability of the bladder 
to expel all of the urine, which remains, becomes alkaline, 
and acts as a source of irritation, thus producing inflamma- 
tion. 

Coyistipation.— This symptom is present in a very marked 
degree. 

Trophic Disturhances. — The temperature of the para- 
lyzed limbs may be raised at first, but later is lower than 
normal. The skin is usually very dry, its nutrition suffers 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 173 

to a very great degree and bed-sores frequently result. The 
slightest pressure upon the skin may produce a blister, 
which is afterward followed by sloughing. Atrophy of the 
muscles involved is usually present. 

Temperature. — The temperature is usually from 101 to 
103 degrees, reaches its height the second or third day, re- 
mains so for several days, then gradually falls and in a week 
is about normal. 

Contractures and Spasms. — These symptoms develop with 
flexion of the legs, and deformities are produced. If the 
cervical region be attacked the arms are involved as well as 
the legs. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

It has to be differentiated from hemorrhage, acute as- 
cending paralysis, multiple neuritis, meningitis, and hys- 
terical paralysis. 

Spinal hemorrhage comes on suddenly and does not 
have fever at first. 

In acute ascending paralysis there are no sensory symp- 
toms and no atrophy. 

In meningitis there is severe pain in the back with 
rigidity of the muscles of the back and limbs. 

In hysteria there is no atrophy and not much rigidity. 



WHAT IS THE PROGNOSIS? 

In favorable cases when improvement commences it 
is very slow and continues for a long time, when recovery 
may be complete. If there is much damage of the cord, 
recovery is not complete and there is usually left some 
weakness with spasm and wasting. Generally there is some 
improvement in every case, which may be followed by fre- 
quent relapses and periods of improvement which continue 
for some years. After two weeks from the time of onset 
the muscles may be tested by the faradic current. If there 
is no response to the current it shows that the gray matter 
of the cord is inflamed; and if there is no change in elec- 
trical irritability from normal the muscles will probably 
recover their tone, as it shows there is no nutritive change 
taking place in the nerves and that the gray matter is not 
involved. Under this condition the prognosis is favorable. 



174 DISEASES OF THE SPINAL COKD AND ITS MEMBEANES. 

In favorable cases the improvement begins to take place in 
a week or two. Cystitis and bedsores may produce such a 
degree of exhaustion as to cause death. In very severe 
cases paralysis of the respiratory organs occurs and death 
takes place quickly. 

WHAT IS THE TREATMENT ? 

General. — Rest is of the first importance, as in 
other spinal cord diseases. Everything possible must be 
done to prevent bedsores. The bed clothing should be 
clean, and great care used to keep it free from wrinkles. 
The patient should be bathed frequently, and no urine 
should be allowed to remain upon the surface of the body. 
Frequent change of position is desirable to prevent bed- 
sores. Solutions of tannin, alum, or alcohol may be used 
upon the dependent surfaces to prevent chafing. 

Dietetic. — Milk, eggs, rice, toast, farina and blanc 
mange may be given in the first part of the disease, being 
followed during convalescence by a full nutrition diet of 
potatoes, meat, such as beef and mutton, chicken, fish 
broiled, and such green vegetables as lima beans and string 
beans. Over-feeding should be avoided, because it is likely 
to make the constipation worse. 

Remedial. — Aconite. — When due to exposure to cold; 
tingling commencing in the feet and spreading upward; 
legs stiff when moved; almost powerless after sitting, with 
numbness; creeping pains in the fingers; great restlessness; 
whole body feels as heavy as lead; faintness on attempting 
to sit up ; formication now in one part, now in another. 

Anacardium. — Paralysis of single parts ; w^ants to lie or 
sit continually; can scarcely move a hand; trembling 
weakness of limbs; sensation as if a baud were tied around 
the body; cramp-like pain in muscles, with contraction of 
joints. 

Arnica. — When due to injury; tingling in the back; 
pain in spine as if not capable of carrying the body; formi- 
cation; lame feeling in low^er limbs; must change 
position often; bed or chair seems too hard; tingling in the 
legs; great heaviness in the limbs; tearing pain in limbs, 
with soreness, trembling, numbness, swelling, or tingling; 
great sinking of strength. 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 175 

Arsenicum, — Burning in the spine; paralysis of the lower 
third of the spinal cord ; loss of strength in the small of the 
back; weakness and numbness of lower extremities with pa- 
ralysis; swelling of the feet; general lack of will power in 
upper and lower extremities; numbness and sensation of 
heaviness; cold hands and feet. 

Dulcamara. — Myelitis after taking cold during menstru- 
ation ; pain in small of back as after stooping a long time ; 
paralysis of arms, they are icy cold, especially during rest; 
weariness, prostration and languor; urine passed involun- 
tarily. 

Gelsemium. — Dull aching in lumbar and sacral regions ; 
cannot walk; muscles will not obey; paraplegia; early stage 
of myelitis; tired sensation of the arms which steadily in- 
creases; fatigue of lower limbs after slight exertion; heavi- 
ness; weight; loss of voluntary motions; calves of the legs 
feel bruised; paroxysmal pains in lower extremities; trem- 
bling of all the limbs; great nervous excitement. 

Rhus toxicodendron. — Myelitis in rheumatic subjects; 
great heaviness, weakness, and weariness of legs, with ach- 
ing pains and inability to rest in any position but for a 
moment ; when walking legs feel as if made of wood ; sensa- 
tion of stiffness on first moving limbs after rest; paresis of 
limbs with numb sensation and difficulty of moving the 
back; cramp-like pain in the limbs; spine affected from 
getting wet. 

CHRONIC HYEUTIS. 

WHAT AKE THE CAUSES OF CHKOXIC MYELITIS? 

The disease occurs most commonly in middle adult life, 
and more frequently in women than in men. Frequent 
exposure to cold or wet continued for a. long time is a very 
common cause of the chronic form. Injury, repeated over- 
exertion, sexual excess, shock, infectious fever, syphilis and 
lead poisoning may produce it; or it. may be secondary to 
the acute form of myelitis. Chronic alcoholism is also a 
cause. 

WHAT IS THE PATHOLOGIC AI. ANATOMY? 

The pia mater is generally thickened over the inflamed 
portion, the cord has a grayish, discolored look, and may also 



176 DISEASES OF THE SFINAL COKD AND ITS MEMBRANES. 

be shrunken. There is an irregular increase of interstitial 
tissue which causes a wasting of the nerve fibres, which un- 
dergo destructive changes from the beginning. After a time 
all fibres disappear in the inflamed area. 



WHAT ARE THE SYMPTOMS ? 

They come on very gradually. The patient notices first 
that he gets tired very easily after walking a little while, 
his legs are heavy, with a prickling and numb sensation in 
the feet and sometimes slight pain in the back; or there 
may be a feeling of constriction about the trunk like a 
girdle. The legs feel stiff and there are exaggerated re- 
flexes. There is loss of sexual power, and a tendency toward 
retention of urine. After a few months there is paresis of 
the lower extremities with some rigidity of the limbs, an- 
esthesia, analgesia, and occasionally pain is felt in the 
back. There may be also some wasting of the muscles. 
Later the urine has to be drawn. When the patient walks, 
it is with a stiff, shuffling gait. The arms become weak and 
stiff, and there is also some wasting, anesthesia and pain. 
In the last stages, the paraplegia becomes complete and the 
patient has to keep to his bed. There is marked atrophy of 
the legs, contractures and rigidity. Cystitis and inflamma- 
tion of the kidneys often develop, or the patient dies from 
some intercurrent disease, such as pneumonia or typhoid 
fever. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

From progressive muscular atrophy it is distinguished 
by the involvement of the sphincters and the sensory dis- 
turbances. 

In meningitis there is more pain in the back, with rigid- 
ity of the muscles of the back. 

In locomotor ataxia there is no marked weakness of the 
legs, and there is the ataxic gait. 



WHAT IS THE PROGNOSIS ? 

It may last for three to fifteen or twenty years. It is 
usually considered incurable, but proper hygienic and medi- 
cinal treatment may stay the progress of the disease very 
materially for many years. The longer it takes the disease 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 177 

to reach its height, and the greater the destruction of the 
spinal cord, the less liability to amelioration. 



WHAT IS THE TREATMENT ? 

General. — Moderate exercise as long as the patient can 
keep about, is of great value; but all exercise should stop 
short of fatigue; plenty of sleep and good, nourishing food 
are of the utmost importance. Freedom from mental worry 
so far as possible. 

Remedial. — Remedies which were suitable for the acute 
form will be found of value here. 



POLIO=MYELITIS=ANTERIOR, ACUTE ATROPHIC PAR= 
ALYSI5, INFANTILE SPINAL PARALYSIS. 

WHAT IS POLIO-MYELITIS-ANTERIOR ? 

It is an inflammation of the gray matter of the anterior 
cornua of the spinal cord. 

WHAT ARE ITS CAUSES? 

It occurs at all ages but is by far most frequent during 
the first ten years of life. The great majority of cases occur 
during hot Aveather. Over-exercise and chilling the body 
when heated may sometimes cause it. Measles, scarlet fever, 
injuries, such as a fall, striking on the head or back, are 
other causes. Sometimes the child seems perfectly well be- 
fore the attack comes on and no cause can be found. 



WHAT IS THE PATHOLOGICAL ANATOMY? 

There is an acute exudative inflammation with destruc- 
tion of tissue without suppuration in the anterior horns of 
gray matter, particularly in the lumbar and cervical enlarge- 
ments. The multipolar cells are destroyed by inflammation, 
the spinal nerve fibres degenerate as a result of defective 
nutrition, and the muscles which they supply undergo 
rapid fatty degeneration and atrophy. Later there is 
sclerosis of the lateral columns of the cord. 



WHAT ARE THE SY3IPTOMS ? 

Prodromal. — There may be first vomiting, loss of appe- 
tite, fever, and all the symptoms of indigestion; or possibly 



178 DISEASES OF THE SPINAL COED AND. ITS MEMBRANES. 



a diarrhea may have been present for a few days before the 
active symptoms manifest themselves. 

Paralysis. — The child may have been put to bed at night 
after suffering from gastric symptoms, or he may have been 
perfectly well on retiring but when 
taken up in the morning all of the 
limbs are found to be paralyzed, or 
only the lower extremities, or even 
only one arm or one leg. In some 
cases the child may be walking along 
and suddenly fall down with both legs 
powerless. Improvement will begin 
slowly in one leg and wasting in the 
other. Sometimes a tingling will be 
felt in one arm and in a few minutes 
the whole arm may become powerless; 
the other arm soon becomes affected 
also, then the lower extremities, until 
all of the members are paralyzed. Im- 
provement usually begins in the mem- 
ber affected last, and only the member 
first affected may remain weak afid 
wasted. Occasionally there will only 
be left weakness and wasting of cer- 
tain sets of muscles in the limbs. The 
paralysis reaches its height from one 
to four days, remains at its height 
from one to six weeks, when improve- 
ment gradually commences. 

Atrophy. — In two or three weeks wasting of the para- 
lyzed limb or sets of muscles will be noticed. 

Reflex Action. — This is lost in the paralyzed limb and no 
knee-jerk can be obtained. 

Fever. — Fever is usually present, temperature running 
up to 101" or 102°, or 104° in severe cases. It may last a 
few hours or days, and then pass away. 

Convulsions. — Convulsions may attend the onset in young, 
children, and be followed by paralysis of one or more mem- 
bers. Sometimes the convulsions are followed by coma and 
the child may remain in that state for three or four days, 
and then gradually begin to recover. Tliese cerebral symp- 




Figrure 28. 

Infantile paralysis from 
polo-myelitis-anterior. 



DISEASES OF THE SPIXAL COKD AND ITS MEMBRANES. 179 

toms always pass away with the other symptoms of general 
disturbance. 

Electrical Reactions. — At the end of the first week there 
is loss of faradic irritability in the paralyzed muscles, but 
they soon begin to manifest reactions of degeneration. 

Deformities. — Tendons which support joints become lax 
when the muscles are paralyzed, the articular surfaces 
fall apart, and dislocation may result. This is more com- 
mon with the shoulder joint. Talipes equinus is common, 
on account of the paralysis of the muscles on the anterior 
portion of the leg and contraction of the posterior muscles. 
In the forearm the pronators may become involved and 
the supinators escape. There are also apt to be paralysis of 
the extensors of the hand and contraction of the flexors. 
Retarded growth of the bones in the affected limb, causing 
the limb to remain shorter than normal, frequently occurs. 
Permanent shortening of muscles may produce displacement 
of the parts to which they are attached. 



WHAT IS THE DIFFERENTIAL, DIAGNOSIS ? 

The diagnosis of polio-myelitis-anterior can easily be 
made by remembering the age of the patient, the sudden 
onset of the paralysis, which quickly begins to improve; 
the absence of sensory symptoms and bladder or rectal 
symptoms, the reaction of degeneration in the paralyzed 
muscles and the arrested growth of the limb. 

From progressive muscular atrophy it is distinguished 
by the preceding paralysis, which was rapidly developed, 
and the reactions of degeneration in the paralyzed muscles. 

From pseudo-hypertrophic paralysis it is distinguished by 
the initial fever, and atrophy of muscles instead of hyper- 
trophy. 

From multiple neuritis by the absence of sensory symp- 
toms such as pain, anesthesia, paresthesia, etc. 



WHAT IS THE PROGNOSIS? 

If the inflammation be in the cervical region, there may 
be paralysis of the muscles of respiration, and death will 
be the result, but such a condition is extremely rare. After 
ten days from the onset of the disease if there is no response 



180 DISEASES OF THE SPINAL COED AND ITS MEMBRANES. 

to the faradic current in the paralyzed muscles, and if 
there are reactions of degeneration and if atrophy has com- 
menced, these muscles will probably not recover their tone, 
whether they be all of the muscles of a limb or only certain 
sets of muscles. In the chronic stage the amount of re- 
covery depends upon the degree of wasting, and the duration 
of the case. If there is no sign of returning power within 
three months, there will not be a great amount of recovery. 
If at the end of a couple of months there is some response 
to the faradic current, improvement may be considerable at 
the end of a few months more. 



WHAT IS THE TREATMENT ? 



General. — The same as that of myelitis, which has been 



given. 



Remedial. — Aconite. — May be given during the stage of 
fever, but will not be of use after the paralysis manifests 
itself. 

Belladonna. — Paralytic, drawing pressure, with weakness 
in right upper arm and forearm, with feeling of weakness 
of the whole arm; heaviness and lameness of legs and feet; 
paralysis of lower extremities ; tired feeling in the limbs; 
hands and feet become cold. 

Caiisticum. — Paralytic weakness of limbs; contraction 
of limbs; paralysis of upper extremities; paralysis of single 
parts caused by exposure to cold wind or draught; restless- 
ness of the body in the evening; gradually appearing 
paralysis. 

Cocculus. — Knees sink down from weakness; totters 
while walking and threatens to fall to one side; legs become 
more and more useless until complete paralysis is present; 
paralytic immobility of lower limbs extending from sacrum; 
great lassitude of the whole body; prostration and exhaust- 
ing sweat of the whole body. 

Gelsemium. — Paraplegia; heaviness and weight in the 
limbs; loss of voluntary motion; great fatigue of lower 
limbs after slight exertion ; coldness of extremities, especially 
of feet, as if in cold water; spinal weakness from exhaustion 
in the early stage of polio-myelitis-anterior. 

Phosphorus. — Loss of power in all the limbs; paralysis 
confined to upper and lower extremities ; complete paralysis 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 181 

after exanthematic diseases ; cerebro-spinal system depressed ; 
over-sensitiveness of all the senses. 

Rhus toxicodendron. — Paralysis of lower extremities 
after exposure to wet; great heaviness, weakness, and weari- 
ness of the legs ; paralysis of the limbs after great physical 
exertion ; great restlessness ; is obliged to turn in every direc- 
tion on account of internal uneasiness. 



ACUTE ASCENDING PARALYSIS. 

WHAT IS ACUTE ASCENDING PARAI.YSIS ? 

It is a rapidly developing motor paralysis which com- 
mences first in the lower extremities, then quickly involves 
the trunk, arms, and finally the muscles of respiration. 



WHAT ARE THE CAUSES ? 

It occurs more frequently in females, and generally be- 
tween the ages of twenty and forty. Alcoholism, severe 
exposure to cold, toxemic states of the blood during con- 
valescence from ■ small pox, diphtheria, typhoid fever, after 
the febrile condition has passed away for some vveeks, are 
causes. It may sometimes follow traumatic conditions, usu- 
ally after an interval when the wound seems to be healed. 
It may sometimes occur in syphilitic patients. 



WHAT IS THE PATHOLOGICAI. ANATOMY? 

Even by the most careful observers no pathological 
changes have been found after death. It is probable that 
the symptoms of paralysis are due to poisoning of the nerve 
elements by some substance within the blood. 



WHAT ARE THE SYMPTOMS ? 

There may be premonitory symptoms, such as general 
malaise, pains in the head and back, accompanied by numb- 
ness and tingling in the extremities about to be paralyzed. 
Soon the patient notices a rapidly increasing weakness of 
the lower extremities, which may go on to complete paralysis 
in a few hours. The feet are first paralyzed, then the legs, 
and finally the thighs. After the lower extremities have 
completely lost their function, the trunk is next involved, 



182 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

then the upper extremities, and finally the muscles of respir- 
ation. Complete paralysis may not take place in all the 
members of the body for two or three days. There may also 
be an inability to swallow, so that the patient has to be fed 
through a tube. The muscles of articulation become in- 
volved to such a degree that the speech is unintelligible. 
The lips may be paralyzed. The eye muscles may also be 
affected so that there may be an inequality of the pupils or 
a slight strabismus. The tingling in the extremities may 
be followed by hyperesthesia of the skin and tenderness of 
the muscles. There may also be some blunting of the sensi- 
bilities, but no complete anesthesia. In the early stages 
reflex action is lost, but as the case recovers it returns. The 
muscles in the paralyzed limbs are flaccid and relaxed, and 
there is usually no wasting and no change of electrical irri- 
tability. The sphincters are not involved. The mind is 
perfectly clear, but the patient may not be able to express 
himself either by speech or sign. 



WHAT IS THE DIFFERENTIAI. DIAGNOSIS ? 

The rapidity of onset, with the ascending character of 
the paralysis, loss of reflex action, without much pain or loss 
of sensation, and the absence of atrophy of the muscles if 
the patient survives, usually make the disease easy to di- 
agnose. 

From polio-myelitis-anterior it is distinguished by the 
absence of atrophy of the muscles and the reactions of de- 
generation. 

From meningeal hemorrhage by the absence of pain. 



WHAT IS THE PROGNOSIS ? 

The disease may run its course and end fatally in forty- 
eight hours, death being due to paralysis of the respira- 
tory muscles. The greater majority of fatal cases end in 
about a week. Sometimes the disease does not attain its 
height for two, three or even four weeks, and then it begins 
to abate, the limbs gradually regaining their power. 
Recovery of the muscles is usually opposite to that of their 
invasion. In favorable cases recovery may be complete in 
three or four months, sometimes in a few weeks. 



DISEASES OF THE SPINAL COKD AND ITS MEMBRANES. 183 
WHAT IS THE TREATMENT? 

General. — Perfect rest in bed is absolutely necessary. 
If the paralysis be due to exposure to cold, hot water bottles 
at the feet and around the trunk and limbs, with plenty of 
covering over the patient, will help to mitigate the symp- 
toms. 

Dietetic. — Food which is easily assimilated should be 
administered; and when there is difficulty in swallo wing- 
liquid food should be given through a stomach-tube. Milk, 
eggs beaten up in milk, soups, gruels and long-boiled rice 
will be the articles most commonly used during the firs^ 
few weeks. 

Remedial. — Aconite. — When due to exposure to cold, 
with excessive restlessness and tossing about; great mus- 
cular weakness and prostration; numbness and tingling in 
the paralyzed limbs. 

Alumina. — Great exhaustion of strength after a long 
walk, with faint and tired feeling which compels him to sit 
down; sitting increases the weakness; and finally complete 
paralysis with numbness in the limbs takes place. 

Cocculus. — Great weakness of the whole body, with 
trembling and exhausting sweat from the least exertion; 
knees sink down from weakness; paralysis of extremities 
comes on ; soles of feet go to sleep while sitting ; hands and 
feet cold and face pale. 

Coniiim. — Paralysis of the voluntary muscles creeping 
from below upwards, unaccompanied by pains or derange- 
ment of intellectual faculties; paralysis of the muscles of 
deglutition and respiration. 

Gelsemium. — Complete relaxation and prostration of the 
whole muscular system, with entire motor paralysis; numb- 
ness and coldness of hands and feet; speech thick; great 
drowsiness; loss of sight; tingling, pricking and crawling 
of the limbs ; mental exertion causes a sense of helplessness 
from brain weakness. 

Rims toxicodendron. — Paralysis of the limbs with numb 
sensation, in consequence of getting wet or after great exer- 
tion, with lameness and soreness of the muscles ; tw^tchings 
of the limbs and muscles ; great restlessness at night. 



184 DISEASES OF THE SPINAL COED AND ITS MEMBRANES. 

DIVERS' PARALYSIS OR CAISSON DISEASE. 

WHAT IS DIVERS' PARALYSIS OR CAISSON IJISEASE? 

It is a form of paralysis which occurs in persons work- 
ing beneath the water when they are exposed to considera- 
ble pressure, the paralysis coming on soon after their return 
to the surface. Persons so affected have generally been 
working at a depth of forty to ninety feet below the surface 
and have been subject to a pressure of about four atmos- 
pheres. 

WHAT IS THE PATHOLOGIC AI^ ANATOMY? 

There are usually congestions and small hemorrhages of 
the spinal ■ cord, with some destruction of nerve tissue. 
There may also be some occlusion of small vessels with 
softening of different portions of the cord and brain. A 
myelitis may ensue as the result of reactive inflammation. 



WHAT ARE THE SYMPTOMS? 

Soon after the patient has returned to the surface, within 
a half hour or an hour, there is noticed considerable pain in 
the ears and in the larger joints. The legs feel heavy and 
are also weak; and in a few minutes the patient is unable 
to move them. There is anesthesia in the paralyzed mem- 
bers; and in severe cases there is paralysis of the sphincters. 
The paralysis may take the form of paraplegia or hemi- 
plegia, and may be complete or incomplete according to the 
severity of the case. The arms are seldom involved alone. 
In cases of hemiplegia, the paralysis is not as severe as in 
paraplegia and passes away in a few hours or a few days. 
In some cases there is sudden loss of consciousness which 
soon deepens into a comatose condition with irregular 
breathing and signs of paralysis of the heart. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The method of onset of the paralysis occurring in divers 
upon their return to the surface, after having worked for 
some time at great depths in the water, are sufficient indica- 
tions for the diagnosis. 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 185 
WHAT IS THE TREATMENT? 

The main treatment is prophylactic. Men working at 
great depths below the water should work only a half hour 
or an hour and then rest for several hours. The same treat- 
ment, both general and remedial, which was outlined in 
acute ascending paralysis will be beneficial here. 



LOCOMOTOR ATAXIA— TABES DORSALIS. 

WHAT IS LOCOMOTOR ATAXIA— TABES DORSALIS ? 

It is an inability to co-ordinate the limbs when moving 
from place to place. 

WHAT ARE THE CAUSES? 

A neuropathic heredity is found in some cases, which is 
manifested in the form of epilepsy, insanity, or other dis- 
eases of the nervous system. Males suffer ten times more 
frequently than females. About one-half of the cases be- 
gin between thirty and forty years of age, and about one- 
quarter between forty and fifty, and some cases between 
twenty and thirty. One cause more than all others pro- 
duces the disease and that is the results of syphilis. It is 
found that a large majority of cases give a history of 
chancre, though the disease is not strictly speaking a 
syphilitic disease, but is secondary to the results of syphilis. 
Locomotor ataxia occurs more frequently in the city than 
in the country, because syphilis is more frtquent in the 
city. Injury such as produces concussion of the spine, ex- 
posure to cold and wet, great mental anxiety, excessive 
fatigue and over-exertion, various acute diseases, such as 
rheumatism and typhoid fever, and alcoholic excesses pro- 
duce the disease. There is a secondary form of locomotor 
ataxia, especially in syphilitic subjects, which follows some 
other spinal cord diseases, such as myelitis and syphilitic 
gummata of the cord. 

WHAT IS THE PATHOLOGICAL ANATOMY? 

There is first a thickening of the coats of the spinal 
arteries with a change in their calibre. The lumen of the 
posterior arteries is increased in size, while that of the ante- 
rior is decreased. As a result of this change in the size of 



186 DISEASES OF THE SPIXAL CORD AND ITS MEMBRANES. 



the vessels^ there is an increased quantity of blood in the 
posterior portions of the cord. On account of this hyper- 
emic condition of the posterior portions of the cord there 
is an increase of the connective tissue in that portion of 
the cord which, after it becomes organized, begins to con- 
tract and causes atrophy and destruction of the nervous 
elements of the cord — a true sclerosis or hardening. The 
most marked changes are found in the lower dorsal and 
upper lumbar segments of the cord. In these positions 
the columns of Burdach are most affected; but when the 
change is in the cervical segments the columns of Goll are 

more markedly changed. The pos- 
terior nerve roots are atrophied up 
to their ganglia. As these changes 
occur in the posterior portions of 
the cord the symptoms must neces- 
sarily be those affecting sensation 
and co-ordination, and this we find 
to be the fact. 




WHAT ARE THE SYMPTOMS ? 

Fulgurating Pains. — During the 
stage of invasion a sharp, shooting, 
lightning-like pain is felt, perhaps 
in the anterior tibial portion of the 
leg, which is extremely severe, lasts 
but a second, and leaves a sore 
feeling behind it. In a few months 
the same pain may occur again, in 
a few weeks still again, and so on, 
increasing in frequency until it oc- 
curs several times a day. This may 
be the first symptom of the disease, 
and may have been present for 
months before inco-ordination 
comes on. 

Inco-ordination of Loiver Ex- 
tremities. — The first symptom of 
inco-ordination may be noticed 
when the patient is bending over the washstand with his 
eyes closed while washing his face. He finds that there is a 



Figure 29. 

Attitude in locomotor ataxia, 

front view. 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 187 



tendency to fall forwards, and lie has to brace himself in 
order to prevent his doing so. A little later he finds that he 
cannot walk in the dark because he is not able to place his 
feet in the proper position to walk unless he can see them. 
If asked to close his eyes and walk along a straight line he 
will not be able to do so. There is no muscular weakness 
or wasting with these symptoms of inco-ordination. 

Reflex Action. — This is lost early in the disease on ac- 
count of the interference of the function of the motor- 
sensory arc. 

Bladder Symptoms. — During the first stage of the dis- 
ease there may be an inability to void 
urine freely, micturition being sluggish. 
This may be followed by a tend- 
ency toward incontinence and the blad- 
der may not be perfectly emptied. The 
retention may be complete or there may 
be overflow-incontinence. 

Sexual Symptoms. — There may be loss 
of sexual power early in the disease, or it 
may be much increased; but this latter 
condition is rare. 

Constipation. — This is an extremely 
common symptom, but there may be a 
paralysis of the sphincter ani. 

Gait. — When w^alking these patients 
usually lift their feet high, as if stepping 
over something, and bring them down 
heavily upon the floor. There is difiiculty 
in keeping the balance when turning 
quickly, and the patient may fall if he is 
not careful. The eyes are kept fixed con- 
stantly upon the ground so as to watch 
each place where the step is to be taken. 
The foot is raised too high, thrown for- 
ward too far, and brought down too sud- 
denly, the whole foot striking the ground 
at one time, giving a peculiar stamping 
noise. 

Attitude. — When standing the feet 
have to be placed far apart in order to increase the base of 
support and to maintain the equilibrium. 




Fig-ure 30. 

Attitude in locomotor 
ataxia, side view. 



188 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

Bracli-Romherg Symptom. — This symptom is present in 
the majority of cases. 

Inco-ordination of Upper Extremities. — The arms are 
sometimes affected in the same manner as the legs, but 
usually not to such a degree, and some cases may escape 
entirely. There is first a difficulty in feeding one's self — 
an inability to guide the food to the mouth. When at- 
tempting to button and unbutton his clothing there is a 
fumbling of the fingers with the buttons, which prevents 
the patient from accomplishing what he desires to do. The 
handwriting may be materially changed in some cases. 

Anesthesia. — Anesthesia is frequently obseryed in the 
lower extremities, especially in the soles of the feet, so that 
the patient is not able to determine whether his feet are 
upon the ground or not. 

Perverted Sensation. — When walking along the street 
there may be a sensation as if there were pebbles in the 
shoes ; the feet feel as if there were cushions filled with air 
under them, or as if the patient was stepping on velvet with 
his bare feet. 

Delayed Sensation. — An interval of from two to thirty 
seconds may be noticed between the contact of a pin in the 
extremities before the pain is felt by the patient. 

Argyll-Robertson Pupil. — This symptom is present when 
the cilio-spinal axis is affected. 

Paralysis of Ocidar Muscles. — This may be transient, 
lasting for a few days or weeks, or it may be permanent and 
complete, and may occur at any stage. Ptosis and strabis- 
mus, and even ophthalmoplegia, may be present. 

Atrophy of the Optic Nerve. — Sometimes an early symp- 
tom, commencing even before inco-ordination is developed, 
and perhaps the condition for which the patient consults the 
physician instead of the inco-ordination, which at this time 
may be very slight. 

Tropic Disturbances. — Local sweating of the palms and 
soles, or of one side of the head, herpes, thickening of the 
soles of the feet, with blisters and perforating ulcers of the 
foot, may be present. Changes in the bones of a joint have 
been noticed, the bones becoming brittle. There is also a 
tendency towards inflammation and swelling which is fol- 
lowed by induration and ossification. There may be a wear- 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 189 

ing away of the cartilage and \vastiiig of the heads of the 
bones, and ossification of the ligaments. There may be also 
either an atrophy or hypertrophy. The hypertrophy is due 
to the development of new osseous tissue. There is a tend- 
ency towards spontaneous fractures and dislocations. 

Gastric Crises. — Occasional attacks of severe pain in the 
epigastrium, passing through to the back, accompanied by 
vomiting and irregularity of the heart's action, have been 
observed. 

Laryngeal Crises. — There may be true laryngeal spasm, 
with loud inspiration and expiration, cough and dyspnea 
similar to those whooping-cough. 

WHAT IS THE CAUSE OF THIS DISEASE ? 

It is divided into three stages: (1). In which there is 
simple loss of knee-jerk, fulgurating pains, Argyll-Robert- 
son pupil and the Brach-Romberg symptom. (2). Distinct 
inco-ordination upon attempting to walk. (3). In which 
walking can be accomplished only by the aid of another 
person. This third stage may go on until there is an abso- 
lute inability to stand. This is also a stage of complications 
in which involvement of the cerebral vessels, acute myelitis, 
and general paralysis of the insane may come on. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

The diagnosis of tabes is determined by the combination 
of the symptoms given. When there is loss of knee-jerk 
with fulgurating pains and the Brach-Romberg symptom 
there is reason to suspect locomotor ataxia. 

In myelitis there are paralysis and exaggeration of re- 
flexes. 

WHAT IS THE PROGNOSIS ? 

Some patients have been cured when in the first stage. 
In the last stage not much can be done except to make the 
patient as comfortable as possible until death intervenes, 
usually from some intercurrent disease. Locomotor ataxia 
may last for years. 

WHAT IS THE TREATMENT ? 

General. — Hygienic measures should be carefully at- 
tended to. Frequent bathing, plenty of sleep, regular work 



190 DISEASES OF THE SPINAL CORD AND ITS MEMBEANES. 

and exercise, if the patient is able to carry them out, should 
be insisted upon. Sometimes the patient must give up busi- 
ness in order to be relieved. Every means which tends to 
conserve vital energy should be used. Electricity is of use 
as a general tonic, both galvanic and f aradic currents being 
used. 

Dietetic. — Wholesome, nutritious food which is easily 
digestsd should be given. During the gastric crises liquid 
food may be of most use. Soft-boiled rice, milk^ gluten 
flour, gruels of various kinds, farina, meat broths and beef 
juice are most suitable. 

Remedial. — Alumina. — Great muscular weakness and 
impairment of co-ordination; weakness of bladder and sexual 
organs; body totters when the eyes are closed; ptosis and 
diplopia; pain in the soles of the feet on stepping as if they 
were soft and swollen. 

Argentum nitriciim. — Cannot walk in the dark without 
reeling ; legs feel as if made of wood, or padded, with insen- 
sibility to touch; tottering, irresolute gait; diminished 
warmth; cannot walk with eyes shut; stands unsteadily; 
loss of pupillary reflexes ; atrophy of the optic nerve ; gastric 
crises ; retention of urine ; loss of sexual desire ; fulgurating 
pains. 

Belladonna. — In the early stage, with inco-ordination of 
both upper and lower extremities ; raises the feet slowly and 
puts the heel down with great force; when walking raises 
his legs as if he had to pass over an obstacle ; fulgurating 
pains. 

Phospliorus. — Atrophy of the optic nerve with flashes of 
light; trembling, especially of the hands while writing; 
great nervous prostration; fulgurating pains in different 
parts of the body, excited by the slightest chill ; great sexual 
excitement. 

Picric acid.— In the early stages when there is great 
sexual desire; great weakness of the legs which tremble; 
numbness and crawling in the legs, with trembling and 
pricking as if from needles; extremities cold. 

Physostigma. — Neuralgic pains, sometimes in the upper 
arms and again in lower limbs; pain, dull, grinding, crush- 
ing; gradual loss of motion of limbs and great prostration 
of the whole muscular system; staggering gait, as if drunk; 
he must see where he is going. 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 191 

Bhus toxicodendron. — Loss of power of co-ordination of 
lower extremities ; staggers ; takes long strides ; steps liigher 
than usual; tearing pains during rest. 

Secale cornutum. — Absence of knee-jerk; fulgurating 
pains; ataxia; difficult, staggering gait; complete inability 
to walk, not from want of power but on account of the 
peculiar unfitness to perform light movements with limbs 
and hands ; feeling as if walking on velvet. 

Zincum. — Beginning of locomotor ataxia; fulgurating 
pains are marked and intense; twitchings in various muscles; 
the whole body jerks during sleep; lassitude, prostration, 
and pains in the limbs, with aching in the lumbar region; 
burning pain in the tibia; impotency. 



PRIMARY SPASTIC PARAPLEGIA, OR PRIMARY 
LATERAL SCLEROSIS. 

WHAT IS PRIMARY SPASTIC PARA^PLEGIA? 

It is degeneration of the antero-lateral columns of the 
spinal cord, producing weakness of the lower extremities 
with spasm. 

WHAT ARE ITS CAUSES ? 

An inherited tendency toward neuropathic conditions,, 
syphilis, concussion of the spine, such as a fall on the back, 
in which the spastic and paraplegic symptoms do not come 
on for two or three years after the fall; repeated exposure 
to wet and cold; childbirth or abortion; inflammation of the 
knee-joints, and, in the congenital form, injury to the brain 
during birth. The disease occurs most frequently between 
the ages of twenty and forty, and with about equal frequency 
in males and females. There is a congenital form or in- 
fantile form of some authors which takes place during the 
early years of childhood. 



WHAT IS THE PATHOLOGICAL, ANATOMY? 

There is a degeneration of the pyramidal tracts, with the 
usual increase of connective tissue and wasting of nerve 
fibres. In some cases there are large numbers of granule 
cells in the diseased parts. The degeneration undoubtedly 
begins in the nerve elements themselves, and many fibres 



192 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

can be seen scattered through the hardened area. This de- 
generation may be traced into the medulla, pons, and cere- 
bral hemispheres. 

WHAT ARE THE SYMPTOMS ? 

Weakness of the Legs. — Gradually increasing weakness 
is the symptom first noticed. The patient finds that he gets 
tired very easily^ that after a short walk his legs feel heavy 
and that if he gets very tired he has to drag one after the 
other with great difficulty. Sometimes there may be a 
weakness of one leg before the other is affected. 

Rigidity of the Extremities. — With the gradually in- 
creasing weakness rigidity of the extremities is noticed; 
there is a slight stiffness of the legs on getting out of bed 
in the morning, which passes away after the patient has 
moved around a little while. After a few months it is 
noticed that the limbs become rigid after the patient has 
been sitting a short time, and it is only with considerable 
difficulty and after continued flexing and extending of the 
limbs that he is enabled to walk. The spasm is more 
noticeable in the extensor muscles, and therefore the limb 
is kept in a straightened position when the patient is sit- 
ting. By grasping the leg firmly above the knee it may 
be gradually flexed and extended until the rigidity passes 
away. If, however, during this process of flexion the leg 
be fully extended it will spring back quickly into a rigid 
position, much like the blade of a clasp-knife when it is 
opened; hence it is called "clasp-knife rigidity." 

Exaggerated Reflexes. — The reflexes are most marked. 
The knee-jerk is excessive, and sometimes by tapping 
the patella tendon when the leg is straight and the 
patient is lying in bed the whole limb will be raised from 
the bed. Ankle-clonus is also marked. If the patient in 
sitting happens to rest the ball of the foot upon the floor 
there will be extremely severe clonic contractions of the 
muscles of the lower leg until he grasps the knee with his 
hands and forces the heel down to the floor. 

The Gait. — The gait is extremely characteristic. In ad- 
vanced stages when the patient attempts to walk he has to 
carry the leg forward as a rigid whole, and scuffs the foot 
along the ground because he is not able to flex the knee or 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 1 93 

ankle. There is also a tendency for the legs to become 
locked, on account of spasm of the adductor muscles of the 
thigh. 

Sensory Symptoms. — Sensory symptoms are generally 
absent, there being at most only a heavy, dull pain in the 
extremities due to the spasm of the muscles. 

Trophic Changes. — The muscles are sometimes enlarged 
on account of their continued over-action. There is never 
any atrophy. 

The Infantile Form. — This form resembles very closely 
the same condition in the adult. There are the same spasm 
of the extensors and exaggerated reflexes, but there is not 
such a degree of rigidity and neither is there apt to be an 
ankle-clonus. Contracture of the calf muscles is usually 
so marked that it is a very serious hindrance to walking^ 
even though the strength of the limbs may be enough. 
The child after a time is usually able to overcome the 
spasm and will be able to walk, although very late. Some- 
times there is a swinging oscillation of the body which 
lasts through life. 

^VHAT IS THE DIFFERENT! Ali DIAGNOSIS? 

The weakness, rigidity, and exaggerated reflexes of the 
lower extremities, without trophic changes or sensory 
symptoms, will always be sufficient to make the diagnosis 
complete, as there is no other disease which has this tripod 
of symptoms. 

WHAT IS THE PROGNOSIS? 

If the disease has not reached an advanced stage there 
may be an arrest of the symptoms and even considerable 
improvement. Complete recovery does not often occur, al- 
though in slight cases it may. If the rigidity has lasted 
for some time and is very marked, with excessive reflex action 
and great weakness, there will as a rule not be much im- 
provement. The prognosis of the infantile form is better 
than that of the adult. 

AVHAT IS THE TREATMENT? 

General. — Absolute rest will sometimes be of great 
service. In any case the patient must avoid over-fatigue in 
walking. Rubbing will sometimes relieve the spasm of the 



194 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

limbs to a very great degree. A course of Turkish baths 
will sometimes be of great service. Electricity should 
never be used, as it only increases the spasm and does just 
what we do not wish it to do. 

Remedial. — Angustura. — Gradual increasing heaviness 
and weakness in the lower limbs; cannot walk quickly; 
limbs feel stiff; threatening paralysis of the legs with 
trembling of the feet ; drawing in the limbs with soreness ; 
limbs get stiff after sitting a while; a painful tension of 
the muscles of the thighs when moving. 

Arsenicum. — Excessive weakness and exhaustion of the 
limbs, obliging him to lie down; contraction of limbs from 
paralysis of the extensors; limbs stiff, lame and cold, with 
occasional cold feeling all over the body; restless; con- 
stantly moving about; cannot remain seated long at one 
time. 

Calcarea carbonica. — Weakness and trembling in the 
legs, especially above and below the knees; cramps of the 
muscles of the legs; spasmodic contraction of the tendo 
Achillis, with violent pain ; weariness of feet so great that it 
seems as if they could not bear the body; sensation in feet 
and legs as if he had on damp stockings; contraction and 
rigidity of the muscles of the Tegs. 

Lathy r us. — Paresis of lower extremities with tremulous 
tottering gait; tendon reflexes exaggerated; no wasting of 
muscles. 

Phosphorus. — Paresis of the lower extremities, with par- 
tial contraction of the affected muscles; formication and 
tearing in the limbs; pain and stiffness in the spine, prevent- 
ing walking; heaviness and sensation of fatigue, especially 
when ascending steps ; great irritability and nervousness. 

Plumbum. — Paralysis, with trembling of the lower ex- 
tremities; extensor muscles more affected than flexors; pain- 
ful contractions of the limbs and cramps of the muscles, 
with shooting and tearing pains; feet cold. 

Rhus toxicodendron. — Lameness of lower extremities and 
joints, with stiffness on rising after being seated for a long 
time; paresis of the lower extremities, with dragging, slow, 
difficult walking; when caused by exposure to wet, strains 
or excessive exertion; painful stiffness; tingling and numb- 
ness, with pains in the small of the back. 



DISEASES OF THE SPINAL (OKI) AM) ITS MEMBRANES. 195 

ATAXIC PARAPLEGIA. 

WHAT IS ATAXIC PARAPLEGIA? 

It is a weakness of the lower extremities, with ataxia or 
inco-ordination, produced by a combined lateral and pos- 
terior sclerosis of the spinal cord. 



WHAT ARE ITS CAUSES? 

Syphilis occasionally; heredity rarely; exposure to cold, 
such as sitting in a draught after perspiring freely, severe 
exertion, concussion of the spine, and great sexual excess. 
In some cases no causes can be traced at all. It occurs most 
frequently in males and usually between thirty and forty 
years of age, but may commence as early as nineteen and as 
late as sixty. 

WHAT IS THE PATHOLOGICAl, ANATOMY? 

There is a sclerosis of both the posterior and lateral col- 
umns of the cord. It differs from the sclerosis in locomotor 
ataxia in not involving the posterior root zones. In the 
lateral columns it is the direct pyramidal tracts that are 
affected. It is not, strictly speaking,' a true systemic dis- 
ease, because it is not limited to a single system of fibres, 
although the pyramidal tracts are the most affected. The 
cerebellar tract is sometimes also affected, and there is usu- 
ally some increase of connective tissue in the unaffected 
columns; but there are no morbid changes to be found in 
the gray matter. 

WHAT ARE THE SYMPTOMS? 

The beginning symptoms are very much like those of 
spastic paraplegia plus inco-ordination. 

Weakness of Lower Extremities. — A symptom which 
gradually increases until the patient is almost unable to 
walk. There may be some weakness of the upper extremi- 
ties, but often the legs suffer alone. The patient gets tired 
easily after walking a short distance. 

Ataxia. — The patient becomes very unsteady on turning 
or walking in the dark, cannot stand with his feet together, 
and falls if his eyes are then closed. When lying he cannot 
touch a designated object with his foot when the eyes are 
closed on account of the inco-ordination. 



196 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

Gait. — There is not the high movement as if he ^Yere 
stepping over something which is characteristic of locomo- 
tor ataxia, but the patient has to steady himself with a 
stick or catch hold of something to prevent him from fall- 
ing, on account of his inability to maintain his equilibrium. 

Reflexes. — There is great increase of the knee-jerk and 
also some ankle-clonus, which steadily increases with the 
inco-ordination and weakness. 

Sensory Sym2:)toms.— There is sometimes a dull pain in 
the legs, in the sacral region, or in the spine after fatigue. 
There is no loss of sensation . 

Inco-ordination of the Ujjj^er Extremities. — This symp- 
tom with cramp-like spasm of the hands is marked in some 
cases. 

Articulation. — There may be an irregular tremulousness 
of the mouth and tongue which produces a slight impair- 
ment of the speech. 

Sexual Power. — It may be lost in the early stages of the 
disease. 

Sphiiicters. — There is apt to be an inability to empty the 
bladder, which consequently may become largely distended, 
with excessively alkaline urine. 

These symptoms may all gradually increase to a certain 
point when the ataxia is lost sight of by the increase of the 
paralysis and the spasm; so that in the last stages of the 
disease the symptoms of spastic paraplegia are most marked. 



WHAT IS THE DIFFERENTIAL. DIAGNOSIS? 

From locomotor ataxia it may be diagnosed by the in- 
crease of knee-jerk, and also the weakness of the lower 
extremities. 

From primary spastic paraplegia the presence of the 
inco-ordination will give the diagnosis. 

From myelitis it is distinguished by the absence of sen- 
sory symptoms. 

WHAT IS THE PROGNOSIS? 

It does not cause death. Usually some intercurrent 
trouble such as bedsores, disease of the kidneys, or cystitis 
may complicate the condition. The patient may live for 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 197 

many years comparatively comfortable, with the exception 
of his inability to move about. 



WHAT IS THE TREATMENT ? 

It is essentially the same as that which has been given 
for locomotor ataxia and spastic paraplegia. 



HEREDITARY ATAXIA— FRIEDREICH'S DISEASE. 

WHAT IS HEREDITARY ATAXIA ? 

It is a form of ataxic paraplegia which occurs at an early 
age, and in several members of the same family. It is called 
Friedreich's ataxia because this physician first described the 
characteristic symptoms of the disease. It is a combination 
of lateral and posterior scleroses of the spinal cord. 



WHAT ARE ITS CAUSES ? 

Heredity is undoubtedly one of the most prominent 
causes, as it occurs so frequently in several members of the 
same family. There may be no direct hereditary ataxia, but 
there is an inherited neuropathic tendency in the patient. 
The disease occurs between the ages of two and twenty, the 
seventh and eighth years of life being those in which the 
disease most often begins. Next frequently it occurs about 
the age of puberty, from twelve to sixteen. Females suffer 
about as frequently as males. The same sex in families are 
most likely to suffer. Several brothers may be affected and 
the sisters all escape; or several sisters may be affected and 
ail of the brothers escape. Isolated cases occur in families, 
but adult cases are rare. Immediate causes cannot usually 
be traced. 

WHAT IS THE PATHOEOGICAI. ANATOMY? 

It is the same as in ataxic paraplegia and locomotor 
ataxia combined. There is degeneration of the lateral col- 
umns as well as of the posterior columns, but it is largely 
in the latter. The posterior nerve roots are also usually 
affected. The pia mater over the posterior columns is gen- 
erally thickened. There may also be some general shrink- 
ing and induration of the pons and medulla. 



198 DISEASES OF THE SPINAL COED AND ITS MEMBRANES. 
WHAT ARE THE SYMPTOMS? 

Inco-ordinatio)t . — This symptom, commencing first in the 
legs and afterward in the arms, is generally the first symp- 
tom manifested. It is shown by the unsteadiness in stand- 
ing and walking. It may be slight at first, but gradually 
increases until the feet have to be placed far apart in stand- 
ing in order to increase the base of support. In walking 
the patient often staggers like a drunken person. When 
closing the eyes the unsteadiness is largely increased in 
some cases, but in others it makes no difference. 

Jerky Inco-ordination. — Manifests in the upper extremi- 
ties of arms, hands and fingers. If the patient attempts to 
carry a tumbler of water to his lips all kinds of angles are 
described by his hands before the desired point is reached. 
Jerking of the head upon attempting a movement is notice- 
able in most cases, and sometimes may amount to an irregu- 
lar tremor. 

Paresis of Lower Extremities. — Marked after the disease 
has been in existence for a little while. 

Speech. — Speech is impaired later in the disease. It is of 
an eliding character. Syllables and words are run together, 
or it is jerky like the extremities. ' 

Nystagmus. — When the eyes are moved sideways or up- 
ward. It is not present when the eyes are at rest or look- 
ing straight forward. This comes on after the limbs have 
become affected, but usually occurs early in the disease. 
There is no strabismus, no optic nerve atrophy, no diplopia, 
and the pupils are usually normal. 

Sensory Sym,ptoms. — Dull rheumatoid pains in the legs 
sometimes occur, but are never severe. There are no ful- 
gurating pains such as are present in locomotor ataxia. 
Sensibility is usually normal. 

Lateral Curvature of the Spine. — It sometimes results 
from unequal weakness of the muscles of the back. 



WHAT IS THE DIFFERENTIAL, DIAGNOSIS? 

The occurrence of jerky inco-ordination, paresis of the 
extremities, loss of reflex action, eliding speech, and nystag- 
mus, in a person under twenty years of age, would probably 
be due to hereditary ataxia. 



DISEASES OF THE SPINAL COKD AND ITS MEMBRANES. 199 

This disease has to be differentiated from locomotor 
ataxia by the absence of fulgurating pains and the involve- 
ment of the sphincters, and by the presence of weakness 
of the muscles and the symptoms mentioned above, in a 
person under twenty years of age. 

From ataxic paraplegia, by the absence of the knee-jerk 
and the age at which the disease commences and also its 
occurrence in several members of the same family. 



WHAT IS THE PROGNOSIS? 

Serious in every case, as the disease is essentially pro- 
gressive. The patient, however, may be made very comfort- 
able and life prolonged many years. 



WHAT IS THE TREATMENT ? 

The treatment is similar to that of other degenerative 
conditions which have just been mentioned. The remedies 
prescribed have to be given according to the indications 
present in the individual case. Such remedies as arsenicum, 
phosphorus, and argentum nitricum will perhaps be most 
frequently indicated. 

PROGRESSIVE SPINAL MUSCULAR ATROPHY. 

WHAT IS PROGRESSIVE SPINAL MUSCULAR ATROPHY ? 

It is a disease characterized by a slowly progressing 
wasting of the muscles of the extremities and trunk, with 
consequent paresis, without any noticeable sensory disturb- 
ances, and due to the wasting of the motor and trophic cells 
in the spinal cord. 

WHAT ARE ITS CAUSES ? 

It occurs more frequently in males than in females and 
commences between twenty-five and forty-five years of age, 
but some cases may commence much earlier and others much 
later. Direct inheritance is not common, but an inherited 
neuropathic tendency is present in about one-third of the 
cases. Great mental anxiety, severe fright, exposure to wet 
or cold frequently repeated, concussion of the spine, and 
syphilis are some of the causes. Injury of a limb may pro- 



200 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES, 

duce a wasting of the muscles of that limb, which soon ex- 
tends to other muscles of the body and finally becomes gen- 
eral. In many cases no cause for the muscular atrophy can 
be found, and sometimes causes which seem to be totally 
inadequate to produce the trouble have really done so. 



WHAT IS THE PATHOI.OGIC AL ANATOMY ? 

In the muscles themselves there may be simply a nar- 
rowing of the muscular fibres, with the striae farther apart 
than normal. There is fatty degeneration, with a granular ap- 
pearance of the transverse striae; as the disease progresses 
the granules become larger until there are distinct globules 
scattered through the sheath. Some fibres are seen in which 
the sheath contains only a few fatty globules. The periphe- 
ral nerves contain degenerated nerve fibres and the ter- 
minal branches which are distributed to the muscles contain 
a larger number. These degenerated nerve fibres are found 
to come only from the anterior roots. The spinal cord is softer 
than normal at the affected part and the lateral columns 
may be gray and translucent. There are also changes in 
the anterior cornua. Most of the large cells are degenerated. 
The nerve fibrilla waste and there is an increase of the 
small angular and stellate cells and connective tissue 
elements. Most of these changes are found in the cervical 
region when the atrophy begins in the arms; but when it 
begins in the legs the changes are greater in the lumbar 
enlargement. There is a distinct degeneration of the ante- 
rior root fibres passing from the cornua through the anterior 
columns. There is also generally degeneration of the pyra- 
midal tracts, the sclerosis varying in extent according to the 
size of the anterior tract and the distance which it extends 
down the cord. Most of the fibres of these tracts seem to 
have completely disappeared in the sclerosed area. 



WHAT ARE THE SYMPTOMS ? 

Pain. — Pain, usually of an aching character but not 
very severe, may occur in the muscles, which afterwards be- 
come wasted. 

Weakness and Wasting. — These generally come on to- 
gether. The weakness may attract the attention of the 



DISEASES OF THE SPINAL CORD AND ITS MEMBEANES. 201 

patient first, or perhaps the wasting is first noticed. When 
the muscles are covered by the clothing the weakness is 
first noticed. If the patient be fat, the wasting may not 
be noticed for some time after the weakness has been in 
existence. 

Hand. — When the hand is affected first an inability to 
perform finer movements of the hand and fingers, such as 
writing, may first attract the attention. Muscular wasting 
usually begins in one hand first, the adductor longus pollicis, 
the thenar muscles and the interossei being early affected. 
The wasting then spreads from muscle to muscle, the ball 
of the thumb becomes flat, the wasting extends upward, 
involving the flexors and extensors of the forearm, and 
later the upper arm and shoulder. The hand becomes thin 
and flattened, depressions form between the metacarpal 
bones on the back of the hand, and between the flexor 
tendons on the palm, due to the wasting of the lumbricales. 
Sooner or later the hand becomes deformed on account of 
the predominance of power in the extensors and abductors 
of the thumb, the so-called ''ape-hand" being the result. 
Atrophy of the interossei and contraction of the long flexor 
and extensor muscles produce what is commonly known as 
the " claw-hand." 

Forearm. — The extensor muscles are atrophied more 
frequently than the flexors, and the supinators usually 
escape altogether. 

tipper Ann and Shoulder. — The deltoid first manifests 
the disease, and the rounded contour of the shoulder be- 
comes changed, the wasting often so marked that the head 
of the humerus can be recognized beneath the acromion. 
Wasting of the other muscles of the upper arm and shoulder 
soon follow that of the deltoid. The biceps suffer more 
than the triceps. The supra- and infra-spinatus are also 
affected. 

Back. — The muscles of the back are usually involved 
early in the disease, and in some cases the wasting begins in 
them. The trapezius usually suffers first, and the rhom- 
boids and erector spinae later. The serratus, latissimus and 
pectoralis major are affected later. The muscles that extend 
the head on the spine are sometimes affected to a very great 
degree, so that there is difficulty in holding the head erect. 



202 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

It is generally inclined backwards, so as to balance it on the 
spine. If it is moved forward, it falls so that the chin rests 
upon the chest and can only be brought back into an up- 
right position by inclining the trunk backwards, when 
with a sudden contraction of the sterno-mastoids and a jerk 
the head is thrown back into an upright position. 

Eesjoiratory Muscles. — These suffer in the majority of 
cases, and are a great menace to the life of the patient. 
Both the intercostals and the diaphragm may be affected. 

Lower Extremities. — Atrophy of the muscles of the legs 
is not so common as that of the arms. The glutei, ex- 
tensors of the knees and the muscles in the front and on 
the outer side of the lower leg are those most commonly 
affected. The wasting in the lower extremities usually 
comes on late in the disease. 

Face. — The face usually escapes the atrophy and is a 
marked contrast to the wasted body. 

Bulbar Paralysis. — It is present in some cases. 

Lordosis. — Lordosis is common when the trunk and hip 
muscles are involved. It is usually the result of weakness 
of the extensors of the hip-joint which causes the pelvis to 
be unduly inclined forward, while the upper part of the trunk 
is inclined upwards. 

Electrical Irritability. — This diminishes as the muscular 
fibres waste, but there is a response to both the galvanic and 
faradic currents as long as a muscular fibre lasts to be acted 
upon. 

Fibrillary Tivitchings. — They occur in almost every case 
and consist in repeated and brief contractions of individual 
parts of muscles. They are most marked when the muscles 
are tapped with the finger, or when the parts are exposed 
suddenly to the cold air. 

Knee-jerk. — Usually excessive. 

Ankle-clonus. — It may be obtained. 

The wasting may go on until nearly all of the muscles of 
the body are involved, and the patient is incapacitated from 
moving about on account of the progressive weakness. 



WHAT IS THE DIFFERENTIAL. DIAGNOSIS ? 

The gradual onset of the weakness and wasting, and the 
slow extension to other muscles make the diagnosis easy. 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 203 
WHAT IS THE PROGNOSIS ? 

The prognosis is usually grave in every case, and yet 
there may be an arrest of the symptoms in old age. The 
danger to life is from extensive involvement of the respira- 
tory muscles, and from bulbar paralysis. If the wasting has 
remained stationary for six months, it will usually continue 
unchanged. Sometimes cases may recover to a very great 
degree, but never completely. The disease usually runs its 
course in about five years, but may last for a great many 
years. Death is produced by some intercurrent disease, or 
by involvement of the muscles of deglutition and respiration. 



WHAT IS THE TREATMENT ? 

General. — Galvanism, faradism, massage, and warm 
baths are often of great use. The muscles should be 
treated by the faradic current, while the galvanic current 
may be applied to the spine. Each application should not 
last more than ten minutes, and should not be given 
of tener than every other day. Never use the current long 
enough to make the muscles tired. 

Remedial. — Argenfum nitricum. — Lassitude and weari- 
ness of forearms and legs; drawing pains in the muscles; 
arms heavy; wasting, particularly of the legs, with para- 
lytic weakness; great nervousness and prostration; weak- 
ness and debility, with rigidity of various muscles; para- 
plegia. 

Arnica. — Arms feel weary, as if bruised by blows; limbs 
ache as if beaten; great weakness; lassitude and sluggish- 
ness of the whole body ; scarcely able to stand ; everything 
feels too hard ; fibrillation in single muscles; twitching in 
all the limbs ; over-sensitiveness of the whole body. 

Arsenicum, — Heaviness of the limbs; painful feeling of 
fatigue penetrating to the marrow of the bones; aching in 
all the limbs; excessive weakness and exhaustion in the 
limbs which oblige him to lie down; limbs stiff and lame; 
a general lack of will power in upper and lower limbs, with 
numbness and sensation of heaviness; contractions of limbs 
from paralysis of extensors. 

Calcarea carhonica. — Wasting of thighs and paresis of 
extensor muscles ; heaviness and painful weight in limbs. 



204 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

and great fatigue on walking ; contractions and rigidity of 
flexors of the arm and fingers; great nervous irritability 
and nervous excitement; trembling in the limbs and con- 
tinuous lassitude ; great loss of power on walking, espe- 
cially in limbs, with exhausting sweat ; great exhaustion on 
awaking in the morning after deep sleep. 

Causticum. — Tearing and drawing in shoulder-blades; 
paresis of deltoid; Gannot raise hand to head; rheumatic 
aching in shoulder; bruised pains in thighs and legs in the 
morning ; stiffness of the legs ; intolerable uneasiness of the 
limbs in the evening ; paralytic weakness of the limbs, with 
contractions and rigidity; restlessness and uneasiness of 
body, with anxiety about heart; faint-like sinking of 
strength. 

Gelsemium. — Fatigue of limbs after slight exercise; 
heaviness; weight; loss of voluntary motion; calves feel 
bruised; pain at night; trembling in all the limbs; limbs 
cold ; cold hands and feet ; deep-seated, dull aching in limbs 
and joints, attended with loss of motion; numbness; feeling 
as if the limbs were going to sleep. 

Phosphorus. — Heaviness, weakness, and weariness in 
lower extremities ; unable to move 'the limbs, which are cold ; 
limbs tremble from every exercise; jerking of single muscles; 
feeling of weakness in the back as if crushed; both lower 
limbs so feeble that the patient is only able to stagger for a 
moment or two with trembling step ; unsteady, stumbling 
gait; arms weak, can hardly move them, they tremble and 
become numb; wasting of hands, with numbness and in- 
sensibility of fingers. 



TUMORS OF THE SPINAL CORD. 

WHAT ARE THE CAUSES OF TUMOKS OF THE SPINAL CORD ? 

The causes are the same for the most part as those which 
produce tumors in other parts of the body. Fatty tumors 
usually grow outside of the dura mater, and occur in early 
life. Malignant tumors come on late in life. Myomata 
occur in middle life. Tubercular growths may occur dur- 
ing childhood, but usually between fiJteen and thirty. Lipo- 
matous growths are congenital. Syphilis and tuberculosis 
produce growths within the spinal canal. Parasitic tumors 



DISEASES OF THE SFINAL COKD AND ITS MEMBRANES. 205 

occur, and are due to the same conditions which produce 
them elsewhere. 

WHAT IS THE PATHOLOGICAL ANATOMY? 

The growths may be outside of the dura mater, inside of 
the dura mater, or within the substance of the cord itself. 
Growths which are outside of the dura mater are called 
extra-dural, and spring from the membrane, or from the tis- 
sues which lie between the membrane and the bone. Growths 
within the dura mater may arise from the inner surface of 
the membrane, from the arachnoid, or from the pia mater; 
and the growths which develop within the substance of the 
cord itself may arise from the pia mater. Lipomatous 
growths are extra-dural, and are due to an overgrowth of fat 
which lies between the membranes and the bone. Enchon- 
droma, sarcoma, and cancerous growths arise from the bones, 
or from the intervertebral tissue. Tumors within the dura 
mater are usually syphilomata, sarcomata, and myxomata. 
The growths within the substance of the cord are syphil- 
omata and gliomata which are the most common; and sar- 
comata, myxomata, and tubercular tumors. 

Growths without the dura mater are always single, but 
sometimes are multiple. The growths outside the cord vary 
in size from a pea to from one to two inches in length. 
Multiple tumors are small. Neuromata or sarcomata may 
occur on the nerve roots and a,re often multiple. 

Tumors produce compression of the cord sometimes to 
such a degree that the cord may be reduced to the size of a 
quill, and may set up a true pressure myelitis with the tissue 
changes which occur in that disease. The location for the 
majority of tumors is the middle cervical region, and the 
upper and lower dorsal regions. 



WHAT ARE THE SYMPTOMS? 



Pain. — This is generally the most prominent symptom 
throughout the whole course of the disease. It may be 
intense, passing along the course of the nerves which 
arise from the spinal cord in the region of the tumor, and 
even in the lower extremities below the lesion. It may be 
sharp, acute, and of a burning character, or it may be stab- 
bing or rending. Sometimes a dull, aching pain is felt be- 



206 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

tween attacks of exaggerated pain. During the severe attacks 
the intensity of the pain is very great. It may be felt 
first on one side and then on the other. Sensitiveness over 
the vertebrae is often felt. 

Anesthesia. — It follows the pain after destruction of the 
nerve has taken place. 

Formication^ Tingling and Numbness. — These are felt in 
the extremities. 

Muscular Spasm. — Common when the tumor arises from 
the membranes. There may be rigidity of the back with 
pain in the region of the tumor. 

Contractures. — Contractures are apt to be developed in 
the limbs. 

Paralysis. — Paralysis of gradual onset is present in 
nearly all cases. Paraplegia most commonly exists, but all 
four extremities may become paralyzed if the growth is in 
the cervical region. Sometimes one leg becomes weak be- 
fore the other. 

Reflex Action. — If the growth be within the lumbar 
enlargement, reflex action is lost. If it be above the lumbar 
enlargement, reflex action is increased. 

Atrophy. — Atrophy of the muscles which are supplied by 
the damaged nerve roots is a prominent symptom in late 
cases. 

All symptoms come on gradually and the location of 
them depends upon the location of the growth. 



WHAT IS THE DIFFERENTIAL, DIAGNOSIS ? 

The diagnosis depends upon the symptoms of a focal 
lesion of slow development, with symptoms of irritation, 
such as pain and rigidity, followed by anesthesia and the 
other symptoms just enumerated. 

From neuralgia it may be differentiated by the constancy 
of the symptoms ; and their long continuance would lead us 
to believe that there was organic irritation. 

From chronic transverse myelitis the differentiation is 
sometimes extremely difficult, but in the latter disease there 
is not the intense radiating pain which occurs with tumor. 

The nature of the tumor will have to be determined in 
the same way as in tumors of the brain. If in a syphilitic 
subject, the tumor would probably be syphilitic in charac- 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 207 

ter. If in a tubercular subject, the tumor would probably 
be tubercular; and in a cancerous subject, cancerous. 



WHAT IS THE PROGNOSIS ? 

This depends upon the nature of the growth. Syphilitic 
growths are sometimes cured. Other growths, unless they 
are in such a position that they can be removed, usually go 
on to a fatal termination. 



WHAT IS THE TREATMENT? 

Surgical. — If the tumor be in such a position that it 
can be removed, surgical measures may be of use. 

Remedial. — Arnica, — Cervical vertebrae very sensitive 
to touch and pressure; formication in extremities; sensation 
like a heavy weight shooting through the spine. 

Arsenicum. — Great exhaustion from the slightest exer- 
tion; stiffness and immobility of the muscles of the back; 
great weakness and restlessness; paraplegia; skin of legs 
cold, soft and flaccid ; the slightest movement impossible ; 
paralysis, with neuralgia of the limbs, and atrophy of the 
muscles, especially of the lower extremities. 

Baryta carbonica. — In sarcomatous tumors; pain in 
lumbar region of spine, followed by paralysis; stiffness in 
the back, can hardly raise from the chair; paralysis of 
flexors of feet, with tension of tendons; dragging in the 
thighs, particularly when going upstairs, on account of 
paralyzed feeling in middle of thigh; constantly weak and 
weary, wishes to lean on something. 

Calcarea carbonica. — Where there is a tubercular dia- 
thesis, with probability of a tubercular growth ; pain in the 
small of the back, with sensation of numbness on the side 
of the back upon which he has been lying ; weariness and a 
feeling of stiffness in anterior muscles of thigh in the 
morning on beginning to walk ; coldness of thighs ; emacia- 
tion of lower extremities with paralysis of extensor muscles ; 
coldness of extremities. 

Cicufa. — Frequent jerks in upper portion of the body 
through the dorsal vertebra and arms ; great weakness in 
arms and legs; twitching of extremities; great depression 
and prostration of strength; weak and powerless muscles; 
lassitude and constant sleepiness. 



208 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

Conium. — Lancinating pains and weight in the back-, 
heaviness and sense of weariness in all the limbs; difficulty 
in using the limbs; unable to walk; numbness of finger? 
and toes; piercing and tearing pains in the extremities and 
in joints; great physical and mental debility; general spinal 
paralysis. 

Graphites. — Pain in small of back as if broken, especially 
on touching it ; pressing, grasping, and twitching in arms 
and legs; weakness in back and loins on walking; pain from 
sacrum down to legs; weakness of all the limbs; weak ex- 
haustion of the whole body; atrophy of the affected parts. 

Hydrastis. — Stiffness in muscles of lumbar region while 
bending over for a short time, causing great difficulty when 
assuming an erect position; dull, heavy, dragging pain 
across the lumbar region necessitating use of arms to rise 
from the seat ; legs feel weak ; frequent sudden attacks of 
faint spells, with profuse cold sweat all over; great emacia- 
tion; cancerous tumors of the cord. 



SYRINGOMYELIA. 

WHAT IS SYRINGOMYELIA? 

It is a disease characterized by the formation of cavities 
within the spinal cord, and the development of gliomatosu 
tissue. 

WHAT ARE ITS CAUSES ? 

It is an exceedingly rare disease, and occurs more fre- 
quently in men than in women, and in those who follow 
some manual occupation, laborers, butchers, etc. Trauma 
may sometimes produce it, and it has been known to follow 
pregnancy and acute infectious diseases. It occurs usually 
between the ages of fifteen and twenty-five. 



W^HAT IS THE PATHOLOGICAL ANATOMY ? 

The seat of the disease is most frequently in the cervical 
and upper dorsal regions. The cavities vary in length. 
They may extend the whole length of the cord, and even up 
into the medulla and pons. There may be one cavity or 
more. They may extend irregularly across the cord, back- 
ward into the posterior horn of the cord, forward into the 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 209 

anterior coruua, or laterally into the white substance. In 
children the cavity may be simply a dilatation of the central 
canal surrounded by a mass of gliomatous tissue. These 
cavities may contain a thin gelatinous liquid. The cavities 
may be formed by the proliferation and subsequent breaking 
down of masses of gliomatous tissue which have become 
imprisoned in the posterior, gray matter in the course of 
development; or they may be formed by the persistence of 
the primitive tube of which the embryonic cord is composed, 
and after a while become enlarged by the breaking down of 
the embryonic tissue forming its walls. Masses of glioma- 
tous tissue are distributed in the region of the cavity. Hem- 
orrhages sometimes take place into the cavities. 



WHAT ARE THE SYMPTOMS T 

The symptoms are usually bilateral. 

Analgesia. — This and the loss of temperature sense, 
(thermo- anesthesia) with retention of the tactile and 
muscular senses, are the first symptoms noticed in the upper 
extremities. 

Pain. — Pain of a dull, heavy, aching character is often 
noticed in the neck and arms, which comes on gradually, and 
persists with more or less variation. 

Atrophy. — Atrophy of the muscles is generally present 
with the above-mentioned symptoms. It comes on slowly, 
progresses gradually, much in the same way as if it were a 
true case of progressive muscular atrophy. It manifests 
itself in both extremities at about the same time. 

Paresis. — Paresis of muscles of the upper extremities 
corresponds with the atrophy, and may go on to complete 
paralysis. Paresis of the muscles of the spine produces 
scoliosis which is common in most all cases. 

Spastic Paraplegia. — Spastic paraplegia develops later in 
the disease, some time after the involvement of the upper 
extremities. 

Trophic Disturbances. — The hands become swollen and 
red, sometimes with an edematous condition. Eczema, 
herpes, and bullae may occur, and painless whitlows mani- 
fest themselves on the fingers, which may destroy the last 
phalanges. Erosions and ulcerations are sometimes present. 



210 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

The nails become brittle, dry, and drop off. Painless frac- 
tures of the bones may occur from slight causes, and ulcer- 
ation and gangrene of soft tissues which necessitate the 
amputation of the hand are common. There may be also 
an enlargement of the capsular ligaments and looseness of 
the joints. ^^ 

WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

In some cases no symptoms of the disease manifest 
themselves, under which conditions it of course cannot be 
diagnosed. The main symptoms, progressive muscular 
atrophy, with thermo-anesthesia and analgesia of the upper 
extremities, with the trophic changes which have been given, 
usually distinguish it from any other disease. 

From leprosy it may be differentiated by the absence of 
the characteristic thickening of the skin of the face, produc- 
ing the so-called "leonine expression." In leprosy the 
anesthesia is distributed along the course of the nerves, and 
the nerves themselves are very much thickened. There is 
no scoliosis in leprosy, and no spastic paraplegia. 



WHAT IS THE PROGNOSIS ? 

Always grave. Nothing can be done to stop the pro- 
gress of the disease. 

WHAT IS THE TREATMENT ? 

General. — The patient should observe all hygienic meas- 
ures necessary to promote health, should have sufficient 
nourishing food, bathe regularly, obtain plenty of sleep, and 
take life generally as easy as possible. 

Remedial. — The remedies applicable to progressive mus- 
cular atrophy will sometimes be of some use in this condi- 
tion. 

nORVAN'S DISEASE— ANALGIC PANARIPIUM. 

WHAT IS MORVAN'S DISEASE? 

It is a name given to a certain group of symptoms first 
described by Morvan of Lannelis, Brittany, in 1883, prob- 
ably of a neuritic character. 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 211 
WHAT IS THE PATHOLOGICAL ANATOMY? 

By some authors it is thought to be identical with syr- 
ingomyelia, but others claim that it is due to a neuritis. In 
some cases that have died from what was supposed to have 
been Morvan's disease, cavities within the spinal cord were 
discovered upon examination. In other cases a neuritis has 
been found in the stumps that have required amputation for 
the trophic lesions. 

WHAT ARE THE SYMPTOMS ? 

Neuralgic Pains, — Pains, neuralgic in character, assail 
one or both hands or both limbs on one side of the body. 
They may be slight or severe in intensity, or may even be 
absent. 

Trophic Changes. — Felons, ulcerations which go on to 
necrosis causing the loss of one phalanx after another. The 
periods between these ulcerative processes may be weeks or 
even years, or they may follow each other in rapid succes- 
sion. 

Sensory Symptoms'. — Anesthesia, thermo-anesthesia, and 
analgesia, distributed over the whole arm and adjoining parts 
of the body and even the face, are present. 

Atrophy and Paresis. — These symptoms present in the 
muscles of the hand and forearm. The muscular wasting 
does not usually extend above the forearm. 

Bulbar Symptoms — Usually present. 

Vaso-Motor Changes. — The skin is usually livid or pale 
and cold to the touch. 

WHAT IS THE PROGNOSIS ? 

The disease is slow in progress, usually extending over 
many years. It does not generally cause death; neither is 
recovery apt to take place. 



WHAT IS THE TREATMENT? 



Surgical. — Amputation of the gangrenous phalanges 
may often be necessary. 

Remedial. — Graphites. — Finger-nails become thick, 
black and rough; matrix inflamed, sometimes with throb- 
bing and numbness, no suppuration, eczema on the back of 



212 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

hands, hands numb and dead with formication extending 
up the arm. 

Lachesis. — Numbness of finger-tips, necrosis of the ten- 
dons of the fingers with much discoloration; stinging, 
pricking intense pains, fistulous openings from which bony 
splinters are discharged. 

Ledum. — Gouty nodosities on hand and finger-joints, 
boring pains on first joint of thumbs with feeling of stiff- 
ness, periosteum of phalanges painful on pressure, conse- 
quence of injuries of nails, perspiration in palms of hands. 

Mercurius. — Inflammation of cellular tissue beneath 
cutis, extremely sensitive to heat and cold, fingers of both 
hands flexed, especially thumb, so that it is completely 
drawn in, weakness of the arms. 

Natnim sulphuricum. — Inflammation and suppuration 
around roots of nails, tingling, ulcerative pain under nail in 
tips of fingers, blisters filled with water on the phalanx, 
pus around root of nail, pain more bearable out of doors. 

Silica. — Nails rough, yellow, crippled, brittle; white 
spots, ulceration around nails, lancinating pains, inflamma- 
tion extends deep into tendons, cartilages and bones, caries 
of fingers, atrophy and numbness of fingers, contraction of 
flexor tendons, profuse sweat in hands. 



SPINA BIFIDA. 

WHAT IS SPINA BIFIDA ? 

It is, as its name implies, split spine, depending upon a 
defect in the closure of the vertebral arches, which leads to 
protrusion of the membranes of the cord in a sac, forming 
a tumor external to the spinal column. This tumor is filled 
with cerebro-spinal fluid. 

HOW MANY VARIETIES OP SPINA BIFIDA ARE THERE ? 

Four; depending upon the degree of deformity. 

(1). Meningocele. — In which one or more of the ver- 
tebral arches have failed to coalesce. It is the simplest form 
and does not disable the patient to a great degree. The 
tumor is covered by the skin of the back and the meninges. 
The cord does not extend into the sac. This form may be- 
come pedunculated, and be cured spontaneously. 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 213 



(2). Meningomyelocele. — It is the most common form, 
and may produce death. If the patient survives there are 
usually paralysis and deformities in the 
feet and legs. The membranes and cord 
both protrude into the sac. On account 
of defective development of the corium 
in these cases the posterior surface of 
the tumor is covered by an exceedingly 
thin membrane, devoid of hair and 
sebaceous glands and of all the charac- 
teristics of true skin. There is also a 
failure of development of some ol the 
elements of a part of the cord within 
the sac, with degeneration of the nerve 
trunks arising from it. As the result 
there is paraplegia, club-foot, and sensory 
and trophic disturbances below the level 
of the lesion. 

(3). Hydromyelocele or Syringo- 
myelocele. — In this variety there is a 
dilatation of the central canal of the cord 
itself so that the tissues of the cord be- 
come the lining layer of the sac. 

(4). Myelocele. — This is a very rare 
form. There is not only a failure of the 
vertebral arches to unite, but the medul- 
lary folds have also failed to coalesce, 
and as the result there is an opening 
which leads directly into the cerebro-spinal canal; the pro- 
tuberance which is outside of this opening is not a sac, but 
a red, pulpy mass of neural tissue, and from its opening 
cerebro-spinal fluid constantly oozes. 




Figure 31. 

Spina bifida in child 
of four years. Tumor re- 
moved at eighteen. 



WHAT ARE THE CAUSES OF SPINA BIFIDA? 

It is a true developmental defect of the cord, and what 
the causes are which produces such an effect is not known. 
Heredity is sometimes a factor. Either one of the parents 
of the child may have had hare-lip or club-foot or hydro- 
cephalus, showing a defective tendency of development 
which has taken the form of spina bifida in the individual 
case. 



Si4 DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 
WHAT ARE THE SYMPTOMS? 

There is a tumor which varies in size from one inch to 
six inches in diameter. It may have a broad base or it may 
be pedunculated. It almost always occurs in the lumbar 
and sacral regions because the vertebrae there are the last 
to become solidified. The skin over the tumor may be nor- 
mal in character, or may be glossy, tough, thickened or 
ulcerated. 

Headache. — A symptom often so intense as to cause ex- 
treme anguish, compelling the child to lie in bed for weeks 
at a time. 

Paraplegia. — Commonly present in these cases. 

Anesthesia. — Anesthesia of the regions below the tumor 
is present in some cases. 

Hydrocephalus. — This is sometimes a complication. 

Mental Defects. — They are common, owing to changes 
evidently within the brain itself. 

General Conditions. — These children are usually puny, 
weak, and poorly nourished. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

The diagnosis is usually easy, the only difficulty is in 
differentiating between it and congenital tumors which may 
occur in the same locality. Of these growths lipoma and 
hygroma are the most common. These, however, are firm 
and resistant, and are composed of solid substances ; while 
spina bifida is cystic and contains a fluid. 



WHAT IS THE PROGNOSIS ? 

Nearly all cases result fatally. The sac generally rup- 
tures, and the child dies from meningitis. Some cases, 
however, live to attain adult life but they are exceedingly 
rare. 

WHAT IS THE TREATMENT ? 

Surgical. — Compression by means of elastic bandages or 
adhesive straps may give some relief to the symptoms, but 
does not effect a cure. Excision of the sac has been success- 
fully accomplished in a few cases. Iodine injection has also 
been employed. (See standard works on surgery.) 



DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 215 

Remedial. — Rjemedies directed toward the general symp- 
toms manifested, such as headache, paralysis, and general 
malnutrition, are sometimes effective in relieving in a measure 
some of the symptoms and making the patient's life more 
bearable. Such remedies as arsenicum, calcarea, baryta, and 
silica may be of use. 



PART VL 

DISEASES OF MUSCLES. 



ARTHRITIC MUSCULAR ATROPHY. 

WHAT IS ARTHRITIC MUSCULAR ATROPHY? 

It is a wasting of the muscles which move a joint, due to 
an inflammation of the joint. The muscles mainly affected 
are those which extend the inflamed joint. If it be the knee 
that is inflamed, the muscles of the foot or thigh will be 
wasted; if the ankle, the calf muscles; if the wrist, the ex- 
tensor muscles of the forearm; if the elbow, the triceps; if 
the shoulder, the deltoid. The flexors may sometimes be 
involved, but the muscles of the limb near by that do not 
move the joint are not involved'. 



WHAT IS THE PATHOLOGICAL ANATOMY ? 

There is simply a narrowing of the fibres of the muscles 
affected, with occasionally longitudinal striation. The sheath 
nuclei are proliferated, and the intermediate substance is in- 
creased in quantity. 

WHAT ARE THE SYMPTOMS ? 

Simple wasting of the muscles with arthritis. If the in- 
flammation of the joint be acute and severe, the wasting 
occurs rapidly, and in a week or ten days the muscles may 
be very greatly diminished in size. The affected muscle is 
involved throughout its whole length and not only the part 
near the affected joint. The wasting may increase for two 
or three weeks, and then become stationary and continue as 
long as the disease of the joint lasts. Electrical irritability 
of the diseased muscles is usually normal to both galvanic 
and faradic currents. There is increased myotatic irritabil- 
ity and increased knee-jerk if the muscles of the thigh are 

(216) 



DISEASES OF MUSCLES. 217 

affected. Aiikle-cloiius may be elicited when the ankle 
joint is affected. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

The moderate degree of wasting of the muscles which 
involves the whole length of the muscle, associated with a 
preceding joint affection, will enable one to make a diag- 
nosis. 

WHAT IS THE PROGNOSIS ? 

If the inflammation of the joint is of short duration, the 
muscles will undoubtedly recover; sometimes the wasting 
persists for a long time after the joint has recovered. 



WHAT IS THE TREATMENT? 

This should be directed toward the inflammation of the 
joint, and not to the wasting. So long as the inflammation 
of the joint persists the wasting will continue, this wast- 
ing being nature's method of keeping the joint quiet until 
it can recover. If passive motion of the muscle, or electri- 
cal stimulation is used, it will tend to act upon the joint 
and keep up the inflammation ; so that rest of the muscle and 
rest of the joint are first to be observed until the inflam- 
matory process has subsided, after which passive motion and 
electrical stimulation of both joint and muscle will assist to 
bring them back to their normal tone. 



PSEUDO=HYPERTROPHIC MUSCULAR PARALYSIS. 

WHAT IS PSEUDO-HYPERTROPHIC MUSCULAR PARALYSIS ? 

It is an apparent enlargement of the muscles with actual 
w^asting of their fibres. 



WHAT ARE ITS CAUSES ? 

It occurs more frequently in males than in females, and 
during the developmental period of childhood. There are 
usually several cases in the same family. In some cases 
while the disease may be congenital, it is not hereditary; 
but in others there may be a direct heredity, and usually on 
the mother's side. In one case a sister had two brothers 



218 



DISEASES OF MUSCLES. 



affected and two sons^ but one daughter escaped. In three- 
fourths of the cases the disease conies on before the tenth 
year. Occasionally it may not come on 
before the eighteenth or twentieth year. 
It may occur as readily among the rich as 
among the poor; and no general constitu- 
tional condition seems to predispose to the 
disease. 

WHAT IS THE PATHOLOGICAIi ANATOMY ? 

The muscles are pale yellowish in color 
and often resemble masses of adipose tissue. 
Fat cells and tracts of nucleated fibrous 
tissue which contain muscular fibres much 
narrower than normal appear under the mi- 
croscope. The fibres preserve their trans- 
verse striation for the most part, but when 
they are narrowed this may have in a meas- 
ure disappeared, either by granular degen- 
eration or by a simple wasting of the 
striae. Empty sarcolemma sheaths may be 
seen when the- narrowing of the fibres is 
greatest. The motor nerves are found to 
be normal, and the sensory nerves are lost 
in the paralyzed muscular tissue. There is 
Pseudo-hypertrophic an overgrowth of connective tissue in the 
paralysis. muscular substance. 




"Figure 32. 



WHAT ARE THE SYMPTOMS ? 

Weakness of the Lower Extremities. — This symptom is 
first manifested by the child walking clumsily, stubs his 
toe, falls easily and rises with difficulty. When going up 
stairs he has to pull himself up by the banisters, or has to 
put his hand upon his knee after he has raised his foot to 
the next step above and push himself up in this way. If the 
child be laid on the floor on his back and asked to rise he 
will first turn himself over on to the anterior portion of the 
body, then drawing his knees up under him and placing his 
hands upon the floor, he lifts his body up until he is resting 
on his hands and knees. He next draws one leg up under him 
and then the other, thus resting upon his hands and feet. 



DISEASES OF MUSCLES. 



219 



The next step is to place his hands upon his knees and push 

himself up straight by bringing his hands further up his 

thighs. 

Muscular Enlargement. — No changes in the size of the 

muscles may be noticed for some time after the weakness 

has come on ; or the change in size of 
may be noticed before the weakness 
has manifested itself, or the enlarge- 
ment may come on with the weakness. 
The muscles in which the enlarge- 
ment most frequently commences are 
those of the calf. The extensors of 
the knee are often enlarged, and occa- 
sionally the rectus or the vastus in- 
tern us alone may be increased in size. 
The flexors of the knee generally es- 
cape. The glutei are usually very 
large. There is also general increase 
in the size of the lumbar muscles. Next 
to the calf muscles the infra-spinatus 
is the most enlarged. The supra- 
spinatus and the deltoid are also af- 
fected. The triceps and biceps are 
sometimes enlarged, though some- 
times both are wasted. 

Gait. — The gait is of a waddling 
character, with the feet carried far 
apart in order to maintain the equi- 
librium. 

Lordosis. — This is usually marked, 
and due to weakness of the extensors 
of the hip, in which the pelvis is in- 
clined forward, and the upper part of 
the body is held far back to keep the 
centre of gravity of the body over the 

33 ^®®** 

Method orarising'from the Deformities.— IIIlq^q frequently oc- 
floor in pseudo-hypertrophic cur, due to shortening 01 the muscles 
parajsis. least affected. The knee-joint may 

become fixed by contraction of the flexors. Talipes equinus 
may result from contraction of the calf muscles. Lateral 




220 DISEASES OF MUSCLES. 

curvature of the spine frequently results from shortening of 
the muscles on one side of the body. 

Knee-jerk. — Diminished and finally lost. 



WHAT IS THE DIFFERENTIAI. DIAGNOSIS? 

The , peculiarity of gait, the mode of rising from the 
floor, the age of the patient, and the gradual increase of 
the weakness make the diagnosis sufficiently easy, espe- 
cially when conjoined with enlargement of the muscles. 



WHAT IS THE PKOGNOSIS ? 

The prognosis is most grave. After ten or fourteen 
years the power of standing becomes lost on account of the 
weakness and contractions of the muscles. After the pa- 
tient stops walking, the disease progresses rapidly, but he 
may live in a helpless condition for several years. Death 
is usually due to some intercurrent disease, such as acute 
pneumonia, bronchitis, or consumption. In some cases the 
muscular power remains fair until after puberty or even up 
to the age of thirty. The course of the disease is slower in 
girls than in boys. 

WHAT IS THE TREATMENT? 

Gen'eral. — The patient should keep up exercise as long 
as possible without becoming over-fatigued. The faradic 
current is of great use in these cases in keeping up the 
muscular tone. The hygienic surroundings should be most 
carefully looked out for and frequent bathing, plenty of 
rest and good nutritious food should be had. It is only by 
keeping up the action of the muscles that contractures can 
be prevented from coming on rapidly. 

Remedial. — Remedies are of no avail except so far as they 
remove any intercurrent trouble which may arise and which 
has a tendency to lower the vital forces. Arsenicum, cal- 
carea, phosphorus, lathyrus, silica and sulphur may be of 
use. 

SinPLE IDIOPATHIC MUSCULAR ATROPHY. 

WHAT IS SIMPLE IDIOFH ATIC MUSCULAR ATROPHY ? 

It is a form of wasting of the muscles which, while it 
occurs perhaps more frequently in youth, may also occur 



DISEASES OF MUSCLES. 221 

in patients well advanced in years. It is not as frequent as 
pseudo-hypertrophic paralysis. There are several varieties: 
Erb's juvenile form, the facio-scapulo-humeral variety of 
Landuzy and Dejerine, characterized by wasting of the 
muscles of the face with those of the shoulder girths; an- 
other variety in which the affection begins in the legs ; and 
still another form called the peroneal type of family amyo- 
trophy by Charcot and Marie. 



WHAT ARE ITS CAUSES? 

There are usually no causes to be traced outside of the 
congenital tendency which is manifested by the occurrence 
of the disease in several members of the same family. Both 
sexes suffer. It may begin as early as two or three years 
and as late as sixty. When the wasting begins in the face 
the disease usually commences in childhood. It may occur 
in many generations of the same family; sometimes four 
or five. 

WHAT IS THE PATHOLOGIC AI. ANATOMY ? 

Only the muscles themselves are affected and the changes 
are similar to those in pseudo-hypertrophic paralysis with- 
out the increase of interstitial tissue and the absence of fat 
cells. Multiplication of nuclei is sometimes seen. As the 
atrophy progresses the connective tissue increases until 
there is a hard, dense myo-sclerosis. 



WHAT ARE THE SYMPTOMS ? 

The disease usually comes on gradually, weakness and 
wasting coming together and being noticed about the same 
time. The wasting generally begins in the upper arms 
and shoulder muscles, except in the facial form, when it be- 
gins in the face first. In some cases the wasting may begin 
in the legs and be limited to them. When the arm muscles 
are affected, the weakness and wasting are observed first in 
the biceps and triceps; but the pectoralis and latissimus 
dorsi may also be largely wasted. The forearm muscles 
usually escape, with the exception of the supinator longus. 
In the face there is a wasting of the zygomatici muscles, 
with a loss of the labio-nasal furrow; the orbicularis oris 



222 DISEASES OF MUSCLES. 

is affected, the lower lip projects, and the face has a 
dull expression. The muscles of the spine are sometimes 
considerably wasted. In the legs the flexors of the hip and 
the extensors of the knee are most commonly affected. In 
the peroneal type the anterior tibial muscles are especially 
affected. Electrical irritability diminishes as the wasting 
progresses. There are no degenerative reactions. Myotatic 
irritability is also lessened or lost. Shortening of some of 
the muscles is sometimes noticed, producing deformities. 
Lordosis is present. 

WHAT IS THE DIFFERENTIAl, DIAGNOSIS ? 

The most important diagnostic points are its presence in 
several members of the same family, and the onset of the 
disease before adult life. When the disease begins during 
advanced life it is extremely difficult to diagnose it from 
spinal muscular atrophy. 



WHAT IS THE PROGNOSIS ?. 

It is difficult to give the prognosis in an individual case. 
When the disease comes on slowly it may progress for 
years and then become arrested and the patient live to old 
age. Sometimes almost every muscle in the body becomes 
affected and the patient is simply a living, breathing skele- 
ton, unable to move or help himself in any way. 



W^HAT IS THE TREATMENT ? 

The same as that for progressive spinal muscular 
atrophy. 

THOnSEN'S DISEASE— MYOTONIA CONGENITA. 

WHAT IS THOMSEN'S DISEASE ? 

It is an hereditary family disease characterized by the 
development of tonic spasms when the patient attempts 
voluntary movement. It is a rare disease. 



WHAT ARE ITS CAUSES ? 

It is, as its name implies, congenital and hereditary. 
Males are most usually affected, and it comes on during 
youth. 



DISEASES OF MUSCLES. 223 

WHAT IS THE PATHOI.OGICAI. ANATOMY? 

The muscular fibres are found to be hypertrophied, the 
striations indistinct, and the nuclei increased. No other 
pathological changes are found in any part of the nervous 

system. 

WHAT ARE THE SYMPTOMS ? 

As soon as the patient attempts to rise a rigidity of the 
muscles comes on which prevents him from moving for a 
time. In a few moments the rigidity passes away, to be re- 
newed when the patient attempts to move again. If, how- 
ever, the movements be continued, the spasm becomes 
weaker and weaker until it finally passes away, after which 
time the patient may be able to walk a long distance with- 
out becoming fatigued; but after sitting again and attempt- 
ing to rise, he is seized with the same spasm of the limbs. If 
the hand is closed tightly, a cramp seizes the muscles and 
he is not able to open his hand until successive attempts 
have been made. If the eyes are shut tightly they cannot 
be opened for some time. The muscles of mastication may 
also be involved, but the spasm occurs most frequently in 
the extremities. The spasms are produced by exposure to 
cold and nervousness, and are overcome by muscular 
exercise. 

WHAT IS THE DIFFERENTIAL, DIAGNOSIS? 

With the symptoms enumerated above present the dis- 
ease cannot possibly be mistaken for anything else. 



WHAT IS THE PROGNOSIS? 

It is bad as far as a cure is concerned, but it does not 
shorten life. 

WHAT IS THE TREATMENT? 

General.— Muscular exercise which stops short of 
fatigue, regular habits, and freedom from mental worry are 
to be observed as far as possible. 

Remedial. — One homeopathic remedy seems to be indi- 
cated, and that is strychnia. 



PART VII. 

DISEASES OF THE SPINAL NERVES. 



NEURITIS. 

WHAT IS NEURITIS? 

It is an inflammation of the nerves. 



HOW MANY FORMS OF NEURITIS ARE THERE ? 

Five. 

Perineuritis. — In which there is inflammation of the 
sheath of the nerves. 

Interstitial Neuritis. — Inflammation of the connect- 
ive tissue binding the separate fibres together. 

Parenchymatous Neuritis. — ^Inflammation of the 
nerve elements proper. 

Simple Neuritis. — Inflammation of one nerve only. 

Multiple Neuritis. — Inflammation of many nerves. 

Any of these forms may be acute or chronic. 



WHAT ARE THE CAUSES OF NEURITIS ? 

Injury by contusions or compression, and by over- 
extension of the nerves; injuries from dislocations, frac- 
tures, and violent contractions of muscles through which 
the nerves pass; extension from adjacent inflammation such 
as when a nerve is situated near a suppurating joint or 
near an inflamed pleura; exposure to cold. General diseases 
may sometimes produce it, such as diphtheria. Metallic 
poisons, alcohol, etc., are other causes. These agencies may 
produce either an isolated or a multiple neuritis. Syphilis, 
cancer and leucocythemia may also produce it. 

(224) 



DISEASES OF THE SPINAL NERVES. 



225 



WHAT IS THE PATHOI.OGICAI. ANATOMY ? 

The changes differ according as the inflammation affects 
primarily the nerve sheath, the connective tissue, or the 

nerve elements proper. 

In acute inflammation 
the affected nerve is 
red and swollen. The 
redness is due to the 
distended vessels 
w^hich are seen on the 
surface. The sv^elling 
is caused by the edema 
or a sero-fibrinous ex- 
udation. Leucocyte- 
like corpuscles sur- 
round the vessels and 
accumulate between it 
and the nerve. Some- 
times there are small 
extravasations of 
blood. These changes 
are limited to the 
sheath and occur 
therefore in perineu- 
ritis. In interstitial 
neuritis lymphoid corpuscles are seen in the substance of 
the fasciculi between the nerve fibres. In the parenchyma- 
tous form the changes in the fibres are those of degenera- 
tion. The myelin of the white substance breaks up into 
segments; the axis-cylinders are interrupted; the nuclei of 
the sheath are increased in number, and the protoplasm 
around them is also increased in quantity. A little later 
the myelin is divided into smaller globules, and the axis- 
cylinder can no longer be distinguished. Finally the 
sheaths become empty and very narrow, and contain only 
nuclei at intervals. 

WHAT ARE THE SYMPTOMS? 

Pain. — This is the most prominent symptom, and is felt 
along the inflamed nerve, and sometimes in the part to 
which it is distributed. It may sometimes involve the 




Figrure 34. 
Leprous neuritis. 



226 DISEASES OF THE SPINAL NERVES. 

whole limb. It may be intense, burning, and boring in 
character, generally worse at night, and increased by move- 
ment or by anything that produces passive congestion of 
the limb, such as coughing, straining at stool, etc. It may 
radiate to distant parts, and even be felt in the opposite 
limb. Sensitiveness of the whole limb to which the nerve 
is distributed may be present. The nerve itself may be felt 
much swollen at the inflamed part. 

Numbness^ Tingling and Hyperesthesia. — These symp- 
toms manifest in the part to which the nerve is distributed; 
and later, anesthesia may be complete as the result of de- 
struction of the nerve. 

Paresis. — Paresis of the muscles supplied by the in- 
flamed nerve is usually present. 

Eruptions. — Herpes and other eruptions may sometimes 
occur upon the skin supplied by the affected nerve. 

Atrophy. — Usually present if the inflammation passes 
into the chronic stage. 

Electrical Reactions. — They are increased in the inflamed 
nerve. 

Trophic Changes. — Redness of the skin; thickening; 
atrophy of the skin or '' glossy skin " ; effusion into the 
joints producing adhesions^ and even ankylosis. 

Fibrillary Twitchings. — Present with the muscular 
atrophy. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

The distribution of the symptoms along a certain nerve 
will readily diagnose the condition. Sometimes the neuritis 
may be mistaken for a neuralgia, but the neuralgic pain is 
more lancinating and sharper than that of neuritis. 



WHAT IS THE PROGNOSIS ? 

Where the neuritis is due to a local suppurative inflam- 
mation it is grave. Neuritis due to trauma is most apt to 
recover. Where there is a neuropathic tendency within 
the individual the prognosis is not so good. Intensity of 
the symptoms will help us as to the prognosis. When the 
nerve is completely degenerated it may be many mouths 
before regeneration occurs. 



DISEASES OF THE SPINAL NERVES, 227 

WHAT IS THK TREATMENT? 

General. — Rest of the affected nerve is of the most im- 
portance. If the neuritis be secondary to some preceding 
inflammation the primary cause shoukl be dealt with first. 
If due to injury or abscess in any part those conditions 
shoukl be met in an appropriate manner. It may be neces- 
sary to place the limb in a splint in order to get the most 
perfect rest. 

Remedial. — Aconite. — When due to dry, cold weather; 
pains almost unbearable at night, worse from pressure and 
heat, better by applications of wet and cold, redness of the 
skin over affected nerve. 

Arsenicum. — Patient extremely weak, pale and haggard 
from the severity of the pains, pains worse at night, com- 
pelling the patient to leave the bed, move the affected part, 
and walk about; better by external heat, worse from cold 
and rest, burning pains as if hot oil coursed through the 
inflamed nerve, periodical aggravation. 

Belladonna. — Excruciating pains, worse by the slightest 
touch, especially in the evening; sharp, shooting, cutting, 
tearing pains commencing in wrist, shooting to the elbow, 
always from the periphery to the centre, better by constant 
motion, paralytic weakness of all the muscles. 

Mercurius. — Follows belladonna; inflamed nerve feels 
like a cord; excessive nocturnal pain worse from the heat of 
the bed; tearing pains in extremities, and twitching of single 
muscles. 

Nux vomica. — Pains worse after midnight or toward 
morning; numb sensation in affected parts as if they were 
asleep; worse from cold; better by warmth. 

Pulsatilla. — Jerking, tearing, drawing pains, shifting 
rapidly from place to place; worse at night and from warmth; 
caused by protracted wet weather. 

Rhus toxicodendron. — Tearing, drawing pains with sen- 
sation of numbness or formication in the affected parts; 
erysipelatous redness of the skin over inflamed nerve; pains 
worse after midnight from heat of the bed and when rest- 
ing; better by motion and warmth ; rheumatic paralysis from 
getting wet or from lying on damp ground. 



228 DISEASES OF THE SPINAL NERVES. 

NEUROMATA. 

AVHAT ARE NEUROMATA ? 

They are tumors involving nerve trunks or their fibres, 
consisting of an abnormal growth of nerve fibres, when they 
are called true neuromata; or of heterologous tissue, when 
they are called false neuromata. The latter type may be 
either sarcoma, fibroma, syphiloma, or any other variety of 
tumor. 

WHAT ARE THE CAUSES? 

The causes of neuromata are generally obscure. Heredity 
is sometimes a cause. Pressure, punctured wounds, or divis- 
ion of the nerve may produce them. 

WHAT IS THE PATHOLOGICAL ANATOMY? 

True neuromata may consist of medullated or non-medul- 
lated nerve fibres. Connective tissue between the nerve 
fibres varies in amount so that the tumor may be firm or 
flaccid. False neuromata are of various kinds, but fibromata 
are most common. Myxoma sometimes occurs, and sarcoma 
and carcinoma occasionally are present. Syphilitic growths 
occur frequently on the cranial nerves within the skull. The 
tumors may be single or multiple. They may vary in size 
from that of a minute swelling to the size of a child's head. 

WHAT ARE THE SYMPT031S? 

In some cases the symptoms are entirely absent, the 
tumor itself being the only evidence of disease. 

Pain. — It may be intense along the course of the nerve. 
It is usually neuralgic in character and sometimes drives the 
patient almost insane. In other cases it is mild in degree. 

Paresis. — Paresis of the muscles supplied by the nerve 
may be present, and may even go on to complete paralysis 
of the part. 

Anesthesia. — It is present when there has been destruc- 
tion of the nerve by pressure of the growth. The growth 
itself may be extremely sensitive or may be without pain. 
The tumors may sometimes be felt as if the}^ were near the 
surface. 

Numbness and Formication. — These symptoms present in 
the parts supplied by the nerve. 



DISEASES OF THE SPINAL NERVES. 229 

WHAT IS THE DIFFEKEXTIAI. DIAGNOSIS? 

If there be pain, numbness, and weakness along the 
course of the nerve, without any sensitiveness or sw^elling 
of the nerve itself, neuroma may be suspected. If it be 
located superficially and can be felt, the diagnosis is then 
certain. 

WHAT IS THE PROGNOSIS ? 

The tumors may grow rapidly and cause complete degen- 
eration of the nerve. Unless the growth can be removed by 
surgical measures, it may produce permanent symptoms. 



WHAT IS THE TREATMENT ? 

Surgical. — In the majority of cases excision is the only 
remedy, but the function of the nerve upon which the growth 
is situated must be taken into consideration before deciding 
upon an operation. 

Remedies are of but little use except so far as they may 
relieve in a measure the neuralgic pains which are the result 
of the pressure of the growth upon the nerve. 



DISEASES OF SPECIAL NERVES. 



CERVICAL PLEXUS AND ITS BRANCHES. 

DISEASES AFFECT THE CI 
BRANCHES 

Neuralgia, paralysis and spasm. 



WHAT DISEASES AFFECT THE CERVICAL, PLEXUS OR ITS 

BRANCHES? 



CERVICO=OCCIPITAL NEURALGIA. 

WHAT IS CERVICO-OCCIPITAL ^EURALGIA? 

It is a neuralgia referred to a part or all of the distribu- 
tions of the first four cervical nerves, but it is the great oc- 
cipital nerve that is most frequently affected. 



WHAT ARE ITS CAUSES? 

It may result from caries of the cervical vertebra, ex- 
posure to cold, strains of the muscles of the back, and it may 
also occur in hysteria. 



230 DISEASES OF SPECIAL NERVES. 

WHAT ARE ITS SYMPTOMS ? 

Pain. — It is usually constant and dull in character, with 
attacks of sharp pain along the course of these nerves. Ten- 
der spots are found at the point of exit of the great occipital 
nerve between the mastoid process and the spine in the tri- 
angle situated between the trapezius and the sterno-mastoid 
muscles, and above the parietal eminence. 

Hyperesthesia of the Scalp. — Prevents the patient from 
combing his hair, as even the moving of each hair produces 
pain. 

These symptoms are bilateral. 



WHAT IS THE PROGNOSIS? 

Usually favorable, except when it occurs in patients ad- 
vanced in life, when it may be a troublesome condition for 
many years. 

WHAT IS THE TREATMENT ? 

The treatment will be given under the head of Neuralgia. 



PHRENIC NERVE. 

WHAT DISEASES AFFECT THE PHRENIC NERVE? 

Paralysis and spasm. 



WHAT ARE THE CAUSES OF DISEASES OF THE PHRENIC NERVE? 

Diseases of the spinal cord or of its membranes, produc- 
ing a disease of the roots of the nerve, may cause impaired 
functions of the phrenic nerve. Paralysis may sometimes 
follow exposure to cold. Injury from wounds in the neck 
sometimes occurs. Tumors of the neck pressing upon the 
nerve may produce disease. Hysteria may also produce pa- 
ralysis of the phrenic nerve. 



WHAT ARE THE SYMPTOMS ? 

Paralysis. — It is usually bilateral. There is no move- 
ment of the abdomen, and the epigastrium and hypochon- 
drium are retracted. There is dyspnea upon the slightest 
exertion. 



DISEASES OF SPECIAL NERVES. 231 

Spasm. — spasm of the phrenic nerve will produce spasm 
of the diaphragm which may be either tonic or clonic. It 
always occurs as the result of tetanus and never alone. 
Clonic spasm of the diaphragm is commonly known as hic- 
cough or singultus. It may be only slight or very severe, 
and continue until it produces death. It is usually due to 
reflex irritation from the abdominal viscera. Disorders of 
the stomach from over-eating, and gastric, hepatic and uter- 
ine diseases may cause hiccough. 

Pain. — It may present along the line of attachment of 
the diaphragm. 

WHAT IS THE DIFFERENTIAL, DIAGNOSIS ? 

The shortened respiration upon the least exertion, with 
retraction of the epigastrium and hypochondrium during res- 
piration, usually very clearly suggests disease of this nerve. 



WHAT IS THE PROGNOSIS? 

This depends entirely upon the cause of the disease. In 
rare cases hiccough may continue for weeks and produce 
such a degree of exhaustion that the patient dies. Paralysis 
of the phrenic nerve may sometimes prove fatal; but the 
J-espiration may be carried on a long time by the aid of the 
intercostal and thoracic muscles. 



WHAT IS THE TREATMENT? 

General. — For paralysis rest is of great importance be- 
cause then the difficulty of breathing is not present. The 
cause which produces the paralysis, whatever it may be, 
must be taken into consideration in the treatment. In 
clonic spasm of the diaphram or hiccough stopping respira- 
tion for a minute will sometimes stop the spasm. Drink- 
ing water, or great emotional excitement may sometimes 
relieve. Inhalations of nitrite of amyl in severe cases is 
sometimes of use. 

Remedial. — Agaricus. — Spasmodic twitching of mus- 
cles, especially face and upper extremities; hiccough shaking 
the whole body, worse evening and when standing; abdo- 
men distended with gas. 

Belladonna. — Violent attacks of hiccough so that they 
jerk the patient up, even with feeling of suffocation; hie- 



232 DISEASES OF SPECIAL NERVES. 

cough with convulsions of arm and leg alternating; violent 
hiccough after midnight accompanied by profuse sweat. 

Ciciita. — Loud-sounding, dangerous hiccough; nausea in 
morning and when eating; burning pressure at stomach 
and abdomen; violent vomiting, with headache; thirst and 
dryness of throat. 

Cyclamen. — Violent hiccough while eating, and for some 
time afterward, or hiccough-like eructations, particularly in 
pregnant women; burning in esophagus, and aching pains 
in stomach extending through the back. 

Hyoscyamus. — Hiccough after abdominal operations ; vio- 
lent hiccough at midnight with involuntary micturition 
and frothing at the mouth; frequent hiccough with cramps 
and rumbling in the abdomen; heartburn. 

Ignatia. — Hiccough from great mental emotions in hys- 
terical subjects. 

Niix vomica. — Hiccough brought on by cold drinks, fre- 
quently coming on before dinner without any apparent 
cause; hiccough from over-eating and from his customary 
tobacco; eructations sour, bitter and rancid. 



BRACHIAL PLEXUS AND ITS BRANCHES. 

DISEASES AFFECT THE B 
BKANCHEJ 

Paralysis, spasm, and neuritis. 



WHAT DISEASES AFFECT THE BRACHIAL PLEXUS OR ITS 

BRANCHES? 



BRACHIAL PARALYSIS. 

WHAT ARE THE CAUSES OF PARALYSIS OF THE BRACHIAL 

PLEXUS ? 

Injury to the plexus itself, pressure of tumors in the 
neck on the nerve trunks, injury of a single nerve or neu- 
ritis. Injuries may be produced by dislocations of the 
shoulder. 

WHAT ARE THE SYMPTOMS OF COMBINED PARALYSIS OF THE 

BRACHIAL NERVES? 

The arm feels heavy and numb as if it were asleep. This 
sensation may pass away in a few moments or a few hours. 
Pain, tenderness, anesthesia, trophic and vaso-motor symp- 
toms may be present in greater or less degrees. Atrophy 



DISEASES OF SPECIAL NERVES. 233 

and changes in the electrical reactions occur when the pa- 
ralysis is of long standing. Loss of power for elevation of 
the arm, and for flexion and extension of the forearm is 
usually present. In the shoulder and upper arm there is in- 
volvement of the deltoid, biceps, brachialis anticus, and 
supinator longus muscles. In the lower arm and hand the 
triceps, flexors of wrist, pronators, flexors and extensors of 
the fingers and the hand muscles are affected. 



WHAT ARE THE SYMPTOMS OF PAKAr,YSIS OF THE POSTERIOR 

THORACIC NERVE? 

This nerve supplies the serratus magnus muscle. There 
is difficulty in raising the arm above the horizontal position. 
The arm hangs helpless by the side. The inferior angle of 
the scapula is nearer the vertebral column than normal, and 
the posterior border projects. 



WHAT ARE THE CAUSES OF PARAL,YSIS OF THE CIRCUMFLEX 

NERVE ? 

This nerve supplies the deltoid and teres minor muscles. 
There is inability to raise the arm, the shoulder becomes 
flattened, the ligaments of the shoulder-joint become re- 
laxed, and there is a concavity formed underneath the 
acromion process. Wasting of the deltoid takes place. 



W^HAT ARE THE SYMPTOMS OF PARALYSIS OF THE MUSCULO- 

CUlTANEOUS NERVE? 

This nerve supplies the biceps and brachialis anticus 
muscles. There is an inability to flex the elbow and supi- 
nate the forearm if it is pronated. 



WHAT ARE THE SYMPTOMS OF PARALYSIS OF THE MUSCULO- 

SPIRAL, NERVE? 

This nerve supplies most of the muscles on the back of 
the forearm and its paralysis produces " wrist-drop," and 
also paralysis of the last phalanges. 



WHAT ARE THE SYMPTOMS OF PARALYSIS OF THE ULNAR 

NERVE ? 

This nerve supplies the elbow and wrist joints, a number 
of muscles, the palmar and dorsal integument of the little 



234 DISEASES OF SPECIAL NERVES. 

finger, and one-half of the ring iinger. There is inability 
to close the hand tightly, and weakness of the little and 
ring fingers. There is a drawing back of the first pha- 
langes, and the second and third phalanges are flexed. 
With atrophy of the interossei and lumbricales the so-called 
" claw-hand " is produced. 

WHAT ARE THE SYMPTOMS OF PARAL,YSIS OF THE MEDIAN 

NERVE ? 

This nerve supplies the pronators, flexors, the radial side 
of the palm, two lumbricales, the integument of the thumb, 
and two and a half fingers on the radial side. There is in- 
ability to fully pronate the arm, the grip is weakened, and 
flexion and abduction of the thumb, with flexion of the first 
and second fingers, are impaired. 



BRACHIAL SPASn. 

WHAT ARE THE SYMPTOMS OF SPASM OF THE BRANCHES OF 
THE BRACHIAL PLEXUS? 

Spasm is the opposite of paralysis, and irritation of these 
nerves would produce spasm in the muscles which they sup- 
ply. The distribution of these nerves has been given under 
paralysis. ^ 

WHAT IS THE PROGNOSIS OF THESE CONDITIONS? 

The prognosis of these spasms and paralysis depends 
upon the causes which produce them. 

WHAT IS THE TREATMENT ? 

Geisteral. — Mild electrical currents, galvanic and fa- 
radic, are of use to tone up the muscles paralyzed. Massage 
is also of use. The spasms are only controlled by the use 
of homeopathic remedies. 

The remedies for paralysis or spasm of these nerves are 
the same as those for paralysis and spasm in other parts of 
the body — always being governed by the individual case. 

BRACHIAL NEURITIS. 

W^HAT ARE THE CAUSES OF BRACHIAL, NEURITIS ? 

It occurs more frequently in women than in men, and 
during the second half of life. It usually comes on in per- 



DISEASES OF SPECIAL NERVES. 235 

sons who are suffering from perverted nutrition and a gen- 
eral lowered tone of the system. There may be a history of 
gout or muscular rheumatism, and they may also have been 
sufferers from sciatica or lumbago. 



WHAT IS THE PATHOLOGICAL ANATOMY? 

It is the same as in any form of neuritis; usually an in- 
flammation of the nerve sheaths, a perineuritis. 



WHAT ARE THE SYMPTOMS? 

Pain. — It is greater in this form of neuritis than in any 
other. It is usually the first symptom and lasts for a 
long time, even after the inflammation has passed away. 
When taken in connection with the general condition of the 
patient, it is an extremely serious symptom. The pain may 
be located in the region of the scapula beneath the bone, or 
in the wrist or back of the forearm. In some cases the pain 
may first be in the plexus itself above the clavicle, or in the 
axilla. It is unusually sudden in onset, and severe from the 
first. Later there is a dull, heavy sensation in the whole 
arm. Sometimes the pain is acute, lancinating, stabbing, or 
burning, and extends along the course of the nerves. The 
paroxysms are induced by movements or may occur spon- 
taneously. 

Hyperesthesia. — Hyperesthesia of the skin where the pain 
has been is commonly met with. 

Flabhiness of the Muscles. — It does not amount to real 
atrophy, such as occurs in an ordinary neuritis. 

Arthritic Changes. — Anchylosis of the joint may take 
place as the result of the severity of the pain. 



WHAT IS THE DIFFERENTIAL. DIAGNOSIS? 

The severity of the pain, its location, its occurrence in 
persons of advanced age, with absence of marked atrophy of 
the muscles, lead us to a diagnosis. 



WHAT IS THE PROGNOSIS? 



Except in slight cases it is usually a tedious malady, 
and it may last for months or even a year or more. Re- 
lapses are common. Recovery is never quite complete. 



286 DISEAi^ES OF SPECIAL NEKVES. 

WHAT IS THE TREATMENT ? 

The same as for the other forms of neuritis. 



DORSAL NERVES. 

WHAT DISEASES AFFECT THE DOKSAI. NERVES ? 

They are mainly of a sensory character, intercostal neu- 
ralgia, mammary neuralgia, and herpes zoster. 



INTERCOSTAL NEURALGIA. 

WHAT ARE THE CAUSES OF INTERCOSTAL NEURALGIA ? 

This occurs more often in women than in men, and it is 
very frequently due to pressure from the corset. It occurs 
more frequently between twenty and thirty-five years of 
age, and during the winter season. Patients suffering from 
this condition are generally anemic, neurasthenic, or debili- 
tated by child-bearing. Lead poisoning, malaria^ and dys- 
pepsia occasionally produce it. 



WHAT IS THE PATHOLOGICAL, ANATOMY ? 

In some cases there may be a neuritis, but generally 
there is a poisoned blood state which produces irritation of 
the nerves. 

WHAT ARE THE SYMPTOMS? 

The disease comes on suddenly. There are sharp, stab- 
bing pains along the course of the nerves, with tender spots 
here and there. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The character and location of the pain will make the 
diagnosis easy if pleurisy and rheumatism can be excluded, 
and the presence of the tender spots will enable us to ex- 
clude these diseases. 

WHAT IS THE PROGNOSIS? 

Generally good in most cases. The disease usually lasts 
from two to six weeks, but may last for several months. 



DISEASES OF SPECIAL NERVES. 237 

WHAT IS THE TREATMENT ? 

The same as that for other forms of neuralgia which 
will be given under the head of Neuralgia. 



MAMMARY NEURALGIA OR HASTODYNIA. 

WHAT ARE THE CAUSES OF MAMMARY NEURALGIA ? 

It may be produced by local tumors of the breast, or it 
may occur in anemic subjects. Injury, pressure from the 
corsets, and large and heavy breasts may produce it. It is 
also common as the result of hysteria. 



WHAT ARE THE SYMPTOMS ? 



Pain. — It is of a neuralgic character and usually in one 
breast. 



WHAT IS THE TREATMENT ? 



This depends upon the cause. The remedies will be given 
under the head of Neuralgia. 



HERPES ZOSTER OR SHINGLES. 

WHAT IS HERPES ZOSTER? 

It is an acute dermatitis secondary to an intercostal 
neuritis. 

WHAT ARE ITS CAUSES? 

Exposure to cold; injury; the medicinal use of arsenic; 
the result of rheumatic and syphilitic poisons, and lowered 
vitality. 

WHAT ARE THE SYMPTOMS? 

Pain. — It is usually one-sided and comes on gradually 
along the course of the intercostal nerves, neuralgic in char- 
acter, acute, lancinating and severe, accompanied by tender- 
ness of the skin. In young persons it may last but a little 
while and then pass away. In older persons it is persistent 
and is often extremely intractable. 

Herpetic Eruption. — After the pain has been in existence 
for a little while vesicles develop along the course of the 
nerve, extending from the spine around one side of the body 
to the anterior median line. These vesicles reach their 



238 DISEASES OF SPECIAL NERVES. 

height in about ten days. Darmg the time the eruption is 
most profuse the pain is less. After it passes away the pain 
is usually more severe. 

WHAT IS THE PROGNOSIS ? 

This affection lasts for a few weeks in most cases; but 
the length of time depends upon the age of the patient; 
it passes away quickly in young persons but is very per- 
sistent in older persons. 

WHAT IS THE TREATMENT ? 

General. — Warm flannel placed over the seat of the 
trouble will sometimes give great relief. 

Remedial. — Arsenicum. — Confluent herpetic eruptions 
with intense burning and blisters; dry and parchment-like 
skin; nausea and marked prostration; worse after midnight 
and from cold of any kind; better from warmth. 

Graphites. — Herpes zoster, especially on the left side; 
large blisters, burning when touched; herpes, exuding a 
sticky matter. 

Iris versicolor. — Herpes zoster, especially on right side; 
tearing, shooting, rapidly shifting pains along the nerves; 
fine eruption, showing black points after scratching; great 
itching at night. 

Mezereum. — Herpes zoster with sharp, stitching, light- 
ning-like pains, sometimes boring, which leave the parts 
numb; worse in bed and from motion; vesicles form a brown- 
ish scab; neuralgic pains continue for some time after the 
disappearance of herpes. 

Rhus toxicodendron. — Right side especially affected with 
incessant itching; burning, tingling, alternating with pains 
in the chest and dysenteric stools; worse in winter and in 
rheumatic subjects. 



LUHBAR PLEXUS AND ITS BRANCHES. 

DISEASES AFFECT THE I.UMI5AR 
BRANCHES ? 

Paralysis, neuralgia and inflammation. 



AVHAT DISEASES AFFECT THE I.UMI5AR PLEXUS OR ITS 

BRANCHES ? 



WHAT ARE THE CAUSES ? 

The plexus itself may be aamaged by abdominal tumors, 
ovarian tumors, tuberculosis of the abdominal lymph nodes, 



DISEASES OF SPECIAL NEKVES. 239 

psoas abscess, and dislocation of the hip-joint. The nerve 
roots from which the plexus arises may be damaged by pres- 
sure in caries of the vertebra, in cancerous diseases of the 
bone, or tumors of the meninges, and inflammations. The 
plexus itself is not often the seat of primary inflammatory 
processes. 

ANTERIOR CRURAL NERVE— PARALYSIS— NEURALGIA. 

WHAT ARE THE SYMPTOMS OF PARAI.YSIS OF THE ANTERIOR 

CRURAL. NERVE? 

There is a loss of power and wasting in the extensor 
muscles of the knee, and lost knee-jerk. If the nerve is 
damaged within the pelvis, the iliac muscle is involved, and 
there is inability to flex the hip or extend the knee properly. 

Anesthesia — Involves the entire thigh, with the excep- 
tion of a strip along the back of the thigh and the under 
side of the leg and foot, produced by paralysis of this nerve. 



NEURALGIA. 

WHAT ARE THE CAUSES OF NEURALGIA OF THE ANTERIOR 

CRURAL NERVE? 

Morbid growths of the spine, or the growth within the 
abdominal cavity, pressing upon the nerve; also inflamma- 
tion extending from the sciatic nerve through the lumbo- 
sacral cord. 

WHAT ARE THE SYMPTOMS? 

Pain. — Along the course of the nerve the pain is more 
or less severe, involving often the entire thigh with the ex- 
ception of a small strip along the back part of the thigh 
and the inner side of the leg and foot. 



OBTURATOR NERVE— PARALYSIS. 

WHAT ARE THE CAUSES OF PARALYSIS OF THE OBTURATOR 

NERVE ? 

Most cases depend upon damage to the lumbar plexus. 
When it occurs alone it is due to the result of pressure dur- 
ing labor. 

WHAT ARE THE SYMPTOMS? 

The chief symptom is the loss of power of adducting the 
thigh. The limb affected cannot be crossed over the other. 



240 DISEASES OF SPECIAL NERVES. 

SACRAL PLEXUS AND ITS BRANCHES. 

WHAT DISEASES MAY AFFECT THE SACKAI. PLEXUS AND ITS 

BRANCHES? 

This plexus may be damaged by intra-pelvic growths, 
by pelvic inflammations, and by compression during labor. 
It may also be the seat of a neuritis or of neuroma. 



SCIATIC NERVE— PARALYSIS. 

WHAT ARE THE SYMPTOMS OF PARAI.YSIS OF THE SCIATIC 

NERVE? 

If the lesion of the nerve be above the middle third of 
the thigh, the flexors of the knee and extensors of the hip 
are paralyzed. If below the middle third of the thigh these 
muscles escape, and the paralysis involves the leg muscles 
only. The limb is held somewhat firmly at the knee by the 
quadriceps extensor, and when the patient walks the limb is 
lifted by flexion at the hip. In paralysis of this nerve there 
is usually anesthesia of the sole and outer side of the foot 
and leg. The nerve may be the seat of a neuritis, which will 
be considered under sciatica. 



EXTERNAL POPLITEAL OR PERONEAL NERVE— PARALYSIS. 

WHAT ARE THE CAUSES OF PARALYSIS OF THE EXTERNAL 

POPLITEAL NERVE? 

Injury from wounds, fractures of the fibula, and pres- 
sure. 



WHAT ARE THE SYMPTOMS? 

There is loss of power in the tibialis anticus, extensor 
longus digitorum, extensor brevis digiti, and peronei mus- 
cles, as the result of which there is an inability to flex the 
ankle and extend the first phalanges of the toes. Foot-drop, 
and after a time talipes equinus may develop. 

Anesthesia. — Is produced in severe lesions of the nerve on 
the outer half of the front of the leg and on the greater part 
of the back of the foot. 



DISEASES OF SPECIAL NERVES. 241 

INTERNAL POPLITEAL NERVE PARALYSIS. 

WHAT ARE THE SYMPTOMS OF PARALYSIS OF THE INTERNAL 

POPLITEAL NERVE? 

Loss of Power. — This occurs in the posterior tibial mus- 
cles, the long flexors of the toe, and the muscles of the sole 
of the foot. There is an inability to extend the ankle-joint 
or to rotate the leg inward when it is flexed. 

Anesthesia. — Of the outer and posterior part of the leg 
and sole of the foot. 

WHAT IS THE PROGNOSIS OF DISEASES OF THE SPINAL NERVES ? 

Many things are to be considered in making a prognosis 
in diseases of the nerves. The first to be considered is the 
cause; whether it may be removed or not, the amount of 
damage which has been done to the nerve, and the duration 
of the disease. Where the trouble has been due to growths 
of various kinds their prognosis will be the prognosis of the 
nerve trouble. Where the troubles are due to a neuritis, the 
amount of degeneration of the nerve must be considelred in 
making a prognosis. 

WHAT IS THE TREATMENT OF DISEASES OF THE SPINAL 

NERVES ? 

This depends upon their cause. Sometimes surgical meas- 
ures, such as the removal of growths and the treatment of 
wounds, will be the treatment for the nerve trouble. In the 
various kinds of paralysis electricity may be of use over the 
paralyzed nerve. The faradic current is the one most fre- 
quently used. 

SCIATICA. 

WHAT IS SCIATICA? 

It has generally been considered a neuralgia of the sci- 
atic nerve, but of late, on account of investigations into its 
pathology, it has been proven to be, at least in the majority 
of cases, a true perineuritis. 



WHAT ARE ITS CAUSES ? 

It is a disease which occurs mainly in middle adult life, 
and is more common in males than in females. There is 
usually a disturbance of the general nutrition, and some of 



242 DISEASES OF SPECIAL NERVES. 

the patients are subject to gout and muscular rheumatism. 
There is undoubtedly an excessive excretion of uric acid. 
The most frequent exciting cause is exposure to cold, such 
as sitting on the wet grass, standing in water, or sitting in 
a draughty water-closet. Pressure on the nerve by sitting 
on the edge of some hard substance, and violent muscular 
contraction may produce it. 



WHAT IS THE PATHOLOGICAL, ANATOMY? 

There is an inflammation of the sheath of the nerve 
which often extends into the interstitial tissues. During 
the acute stages there are redness and swelling of the sheath, 
and soDietimes minute hemorrhages. 



WHAT ARE THE SYMPTOMS V 

Pain. — Along the course of the nerve trunk pain is the 
pathognomonic symptom. It is first experienced only upon 
motion, particularly when the nerve is put on the stretch. 
As the disease continues the pain becomes more constant 
until finally it is continuous. There is usually a dull, 
heavy ache throughout the whole limb, with acute, agoniz- 
ing pain which may be sharp and lancinating, or dull along 
the nerve trunk. Sometimes it is of a burning character, 
usually worse at night. After a time there is tenderness of 
the nerve trunk to pressure. The pain is usually most in- 
tense above the hip-joint, at the sciatic notch, about the 
middle of the thigh, behind the knee, below the head of 
the fibula, behind the external malleolus, and on the back 
of the foot. 

Abnormal Sensations. — They may be felt over the area 
supplied by the affected nerve, such as numbness, tingling, 
formication, paresthesia and anesthesia. 

Atrophy. — Atrophy of the muscles supplied by the nerve, 
with paresis, is present to a marked degree in severe, long- 
continued cases. 

AVHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

The diagnosis rests upon the position of the pain along 
the nerve trunk, but the main difficulty is to decide whether 
the sciatica be primary or secondary. If secondary it is 



DISEASES OF SPECIAL NEKVES. 243 

usually due to disease of the hip-joint or to disease in the 
pelvis. These, however, will generally manifest themselves 
in their own peculiar way, and will usually be easily deter- 
mined. In every case of sciatica great care should be used 
in the examination of the patient to determine the cause of 
the trouble. 

WHAT IS THE PROGNOSIS ? 

This is usually favorable, but most cases run a very slow 
and tedious course, the duration depending largely upon the 
severity of the symptoms. Ordinary attacks last for a week 
or two to several weeks, but some cases may last for a year 
or two, during which time a considerable degree of wasting 
may take place. 

WHAT IS THE TREATMENT ? 

General. — The patient should avoid all exposure to 
cold or wet, and in severe cases the limb should be kept ab- 
solutely quiet, as in other forms of neuritis. Many meas- 
ures are used in the treatment of this disease, but with the 
exception of general rest of the parts nothing will relieve 
the trouble so quickly and permanently as homeopathic 
remedies. Even the severest forms of the disease may be 
speedily relieved by the properly indicated remedy. 

Dietetic. — All sweets should be prohibited in some of 
these cases, especially those due to rheumatic origin. This 
is extremely important, because many cases are made de- 
cidedly worse, attacks being even brought on by over-indulg- 
ence in sweets. With the exception of this, any nutritious 
food may be given. 

Remedial. — Aconite. — Inflammatory irritation of the 
nerve sheath, with darting, burning, benumbing pain as if 
the part were going to sleep, worse during night and move- 
ment, especially in early cases. 

Ammonium muriaticum. — Severe and long-continued sci- 
atica; pain in left side as if the tendons of the hip were 
too short; limps on walking; entirely relieved when lying 
down; sense of contraction of the leg. 

Arnica. — From over-exertion ; burning, stinging, tearing 
pains; numb and bruised feeling; changes position con- 
stantly as if everything on which the limb rested felt too 
hard. 



244 DISEASES OF SPECIAL NERVES. 

Arsenicum. — Typical regularity of the pains; worse at 
night; unbearable toward midnight; burning, tearing pains 
with great restlessness; great weakness and prostration. 

Belladonna. — Pain in the hip-joint, especially at night; 
sensitiveness to touch, even of the clothing; the least con- 
cussion, and even the stepping of other persons in the room 
aggravates; worse by the least draught of air. 

Bryonia. — Pain in lumbar region extending to the thigh; 
worse by sitting up, by moving, and late in the evening; 
atrophy and emaciation of the effected limb. 

Colchicum. — Sciatica of the right side; sharp, shooting 
pains in the sacral region extending down to the knee; must 
keep perfectly quiet; pain sets in suddenly, is constant and 
intolerable. 

Eiipatorium. — Severe shooting pains along the course of 
the left sciatic nerve, producing a palsied sensation, espe- 
cially after motion. 

Gnaphalium. — Intense, dull, darting, cutting, or burning 
pain along the nerve, with feeling of numbness, rendering 
exercise very fatiguing; worse from lying down, from mo- 
tion and stepping; better when sitting in a chair. 

Bhus toxicodendron. — Especially when caused by ex- 
posure to wet, or straining in lifting; stinging, burning, 
tearing pain with a sensation of coldness, numbness, formi- 
cation, and paralytic stiffness of the limb, increasing during 
rest and when beginning to move; relieved only for a short 
time by motion. 

Silica. — Pains shoot through the extremity at the mo- 
ment when the foot is raised, as when ascending; twitching 
of limbs day and night; limbs go to sleep easily. 



nULTIPLE NEURITIS OR POLYNEURITIS. 

WHAT IS MULrTIPLE NEURITIS? 

It is an inflammation of many nerves, and its most char- 
acteristic features are its multiplicity, its symmetry, and 
its peripheral distribution. 

WHAT ARE ITS CAUSES ? 

It is a disease of adult life, and occurs between twenty 
and fifty years of age. It is more common in females than 



DISEASES OF SPECIAL NERVES. 245 

in males. Exposure to cold and insufficient nourishment 
may help toward the production of the disease. It undoubt- 
edly is due to a widespread systemic poisoning. There are 
several forms of multiple neuritis according to their causa- 
tion: toxic, due to the presence of lead, arsenic, silver, or 
alcohol within the blood; toxemic, due to some virus within 
the blood the nature of which is not wholW known, and it 
may primarily produce a polyneuritis such as occurs in lep- 
rous neuritis, or it produces some definite disease which is 
followed by multiple neuritis, such as diphtheria, small-pox, 
typhoid fever, tuberculosis, and syphilis; endemic, due to 
local organisms such as malarial neuritis and beri-beri; rheu- 
matic, in which the multiple neuritis follows exposure to 
cold; cachectic, when due to some general malnutrition. 



WHAT IS THE PATHOLOGICAL ANATOMY? 

This corresponds to that described as occurring in simple 
neuritis, except that the nerve fibres suffer more than the 
connective tissue. 

WHAT ARE THE SYMPTOMS ? 

According to the symptoms there may be three forms of 
the disease: motor, in which there is loss of power ^vith no 
sensory symptoms; sensory in w^hich there is no marked 
muscular weakness or inco-ordination: ataxic, in which there 
may or may not be any sensory symptoms, but inco-ordina- 
tion predominates. The symptoms may come on suddenly 
or may be some little time in developing. 

Motor Weakness. — It ma}^ involve either the upper or 
lower extremities or both, but always corresponding limbs 
on both sides and their extremities, the hand and foot first, 
and to the greatest extent. There is difficulty in balancing 
on account of the weakness of the feet, and also difficulty in 
performing the finer movements with the hands, especially 
in extending the wrist, so that w^rist-drop is a most con- 
spicuous symptom. There is also an inability to raise the 
toes from the ground in walking, owing to the weakness 
which produces foot-drop. 

Sensory Symj^toms. — Tenderness of the muscles and 
hyperesthesia of the skin, involving especially the soles of 
the feet, the palms of the hands and tips of the fingers are 



246 DISEASES OF SPECIAL NERVES. 

common features. There is also tenderness along the nerve 
trunk affected. Numbness, tingling and paresthesia, and a 
dull, burning pain deep in the limbs are also present. 

Inco-ordination. — This is present in the arms and legs, 
but affects the latter most frequently. It is not so severe 
as in locomotor ataxia, but prevents the patient from per- 
forming fine motions with his hands, and from walking as 
steadily as he should. 

Atrophy. — This may become extreme in some cases and 
affects only the muscles to which the diseased nerves are 
distributed. 

Reflex Action. — Whenever there is weakness in the legs, 
the knee-jerk is lost; and the superficial reflexes are usually 
lost where the cutaneous nerves are affected. 

Electrical Irritability. — It is usually lost. 

Trophic Changes. — Similar to those in simple neuritis. 
There is glossy skin, adhesions of the joints, thickening of 
the skin, nails becoming brittle and falling off, hair becom- 
ing coarse and falling out. 



WHAT IS THE DIFFERENT! AI. DIAGNOSIS? 

The diagnosis depends mainly upon the combination of 
motor and sensory symptoms described, their symmetrical 
distribution in opposite limbs, particularly in their extrem- 
ities, and the tenderness of the skin, nerve trunks, and mus- 
cles. Bilateral wrist-drop and foot-drop also suggest the 
disease. 

From locomotor ataxia it may be differentiated by the 
presence of the foot-drop when the patient walks, and the 
absence of fulgurating pains. 

From progressive muscular atrophy by the wasting fol- 
lowing only the course of the nerves affected, and not ex- 
tending to neighboring muscles. 

From polio-myelitis anterior by the symmetrical localiza- 
tion of the weakness, and the presence of tenderness over 
the inflamed nerve trunks. 



WHAT IS THE PROGNOSIS? 

Very acute and severe cases may terminate fatally. The 
prognosis depends entirely upon the severity and suddenness 



DISEASES OF SPECIAL XEEYES. 247 

of the onset. Some cases come on gradually and last for many 
months or even years. When electrical irritability begins 
to return the prognosis is more favorable. The disease may 
last from three to eighteen months and gradually end in re- 
covery. Sometimes permanent contractures occur. 



WHAT IS THE TREATMENT ? 

General. — It is necessary as early as possible to determ- 
ine the cause of the disease and remove it. Rest is of the 
utmost importance, and except in very mild cases the patient 
should be in bed. Warm fomentations may be applied over 
the tender nerves, and the tender limbs may be wrapped in 
cotton wool. Electricity should never be used during the 
early stages of the disease, but may be of use after the in- 
flammatory condition has passed away and only the atrophy 
is left. 

Dietetic. — The diet must consist of plain, nourishing 
food without stimulants. 

REMEDiAL.^-The remedies for simple neuritis will be of 
use here. ' 

BERI=BERI OR KAKKE. 

WHAT IS BERI-BERI ? 

It is an endemic multiple neuritis which is very preva- 
lent in China, Japan, and in the islands of the Pacific Ocean. 



WHAT ARE ITS CAUSES ? 

It depends upon a specific organism present in the blood, 
which produces the disease. It is an infectious malady, but 
repeated opportunities of infection are necessary. Insufti- 
cient food, or food lacking in albumin, is considered a cause, 
and it is owing to this latter fact that in the countries 
where rice is a staple article of diet it is most common. It 
occurs very frequently in sailors to whom a variety of food 
has been denied. It is undoubtedly propagated in water 
and conveyed in that way. It affects young males between 
eighteen and twenty-five almost exclusively. 



WHAT IS THE PATHOLOGICAL ANATOMY ? 

The same as in other forms of multiple neuritis. 



248 DISEASES OF SPECIAL NERVES. 

^VHAT ARE THE SYMPTOMS ? 

The disease comes on gradually, and may be mild or 
severe. The symptoms are those of multiple neuritis with 
the addition of edema and effusion into the serous cavities, 
with great liability to cardiac disturbances. 

Weakiiess of the Legs. — It is usually the first symptom 
noticed, and prevents the patient from walking as much as 
usual. 

Sensory Symptoms. — Numbness and pain come on soon 
after the weakness. 

Palpitation. — Palpitation of the heart, with shortness of 
breath, epigastric oppression and loss of appetite, soon 
follows. 

Pulse. — The pulse may be irregular and dicrotic. 

Edema. — There is edema of the extremities, and also in 
severe cases of the whole body, which may be very great in 
degree, preventing the patient from lying down, and caus- 
ing rupture of the skin. 

There are three forms of severe cases: the atrophic or 
dry, in which the symptoms come on slowly, but soon in- 
crease with great rapidity until there is paralysis of all 
the muscles of the body, with excessive muscular wasting, 
pain, and paresthesia; the hydropic or wet, in which the 
body is enormously swollen, with subcutaneous effusion, as 
well as effusion into- the serous cavities; the pernicious, 
which is a combination of the other forms but occurs with 
extreme intensity. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The diagnosis can only be of difficulty in the very be- 
ginning of the disease, or if the patient is not known to 
have been exposed to infection. Later in the disease the 
symptoms are so well marked that a mistake cannot readily 
be made. 

WHAT IS THE PROGNOSIS ? 

This varies according to the severity of the disease. Mild 
cases usually recover. Severe cases die within two weeks of 
the onset of the disease. 



DISEASES OF Sl'ECIAL NERVES. 249 

WHAT IS THK TREATMENT? 

General. — Remove the patient from the infected district 
as early as possible and he will then usually begin to 
recover. 

Dietetic. — Change of diet is of the utmost importance. 
A greater variety of food containing plenty of albumin is 
absolutely necessary. 

Remedial. — Apocynum, Arsenicum^ China^ Digitalis^ and 
Strophantus^ are the remedies that will be most frequently 
called for. 

LEPROUS NEURITIS, OR LEPROSY. 
what is leprosy? 

It is a chronic infectious disease of parasitic origin, 
characterized by the production of new cell formations in 
the cutaneous surfaces, and in the connective tissues of the 
nerves. 

what are its causes ? 

It depends upon the presence of living organisms within 
the blood. It may occur at any time of life, but most fre- 
quently during adult life. There are two varieties, called 
the tubercular or tegumentary ; and the anesthetic or tropho- 
neurotic type. Climate, race, soil, food, bad hygiene, and 
malaria are causative factors. It is prevalent in India, China, 
Turkey, the West Indies, Portugal, Russia, and the Hawaiian 
Islands. Sporadic cases occur in some parts of the United 
States; in Minnesota, Iowa, Wisconsin, and along the Pa- 
cific Coast. 

WHAT IS THE PATHOLOGICAL ANATOMY ? 

The bacilli leprae are found in diffuse and nodular infil- 
trations on the skin and mucous membranes, and in the in- 
terstitial connective tissue of the peripheral nerves. The 
appearance of a lepra tubercle is much like that of tuber- 
culosis. The bloodvessels are dilated and their walls are 
thickened. The nerve sheaths are increased in thickness, 
and the nerve fibres themselves undergo slow wasting. 



Il AVHAT ARE THE SYMPTOMS OF TUBERCULAR LEPROSY? 

Prodromal. — There may be a condition of general debil- 
ity which manifests itself by weariness after slight exertion, 



250 DISEASES OF SPECIAL NERVES. 

witli a sense of depression, heaviness and tendency to sleep. 
Febrile symptoms, preceded by sensations of chilliness or 
even rigor, are quite common in this stage. The fever is 
usually of an intermittent type. These prodromal symp- 
toms niay extend over a period of many months and are f ol- 
lov^^ed by the so-called eruptive stage. 

Cutaneous Manifestations. — There is first a heightening of 
the color of the skin over the malar prominences, and it has a 
shiny, glossy appearance. There is moreover an increase of 
the secretions of the skin, it has a greasy feel and appearance, 
and sweat is abundant. Sometimes there may be suppres- 
sion of secretions, with falling of the hair, especially of eye- 
brows and lashes. The redness of the skin may appear and 
disappear several times before tuberculosis is established. 
The eruptions are most common on the face, hands and feet, 
but may appear on any portion of the trunk or limbs. The 
macules are oval in shape, of a reddish-brown or coppery 
color, fading into a dirty yellow. The skin of the face is 
more or less thickened and swollen, and presents an edema- 
tous appearance. The tubercles may be about the size of a 
pea or of a walnut, and several of them may coalesce and 
form elevated patches of considerable size. The regions 
most affected are the forehead, nose, lips, chin, ears, hands 
and forearms, especially the extensor surfaces. 

Subjective Sensations. — Itching and burning of the skin, 
rheumatic pains, cramps in the lower limbs, various forms 
of neuralgia with a sensation of numbness or deadness, espe- 
cially in the lower limbs. 

Mucous Surfaces. — These are also the seat of infiltra- 
tions which break down and form ulcers, causing more or 
less destruction of tissue. The nose, mouth and pharynx 
are most commonly involved. One of the early symptoms 
of leprosy is a snufiling nasal respiration, due to ulceration 
of the nasal septum. 

WHAT ARE THE SYMPTOMS OF ANESTHETIC LEPROSY? 

The symptoms of this form are more of a neurotic char- 
acter. There is extreme itching and burning of the skin, 
hyperesthesia and pains of a lancinating, boring character 
in the deeper structures, followed by sensations of numb- 
ness or deadness, and later by complete anesthesia in spots, 



DISEASES OF SPECIAL NEEVES. 



251 



especially in the regions supplied by the ulnar and peroneal 
nerves. 

Cutaneous Changes. — Dryness and scaliness of the skin 
with formation of pem- 
phigoid blebs upon the 
fingers and toes, which 
rupture after a few hours, 
leaving excoriations like 
superficial burns, Avhich 
upon healing leave pig- 
mented stains. The erup- 
tion may develop upon 
one portion of the body 
after another, and after a 
time become a reddish- 
brown color in patches. 
The centre of the patch 
becomes thin, white, 
atrophic and wrinkled, 
and there is usually a 
denudation of the hair. 
The blanching may affect 
a large portion of the 
body. These atrophic 
patches are usually with- 
out sensation. 

Paralysis. — Paralysis 
of certain nerves, with atrophy of the muscular tissue which 
they supply, is common in this disease. 

Mutilation of the Hands and Feet. — The bones of the 
fingers and toes may be lost without ulceration, by a pro- 
cess called osseous absorption. It affects one finger after 
another, the tissues retracting and the nail retreating, until 
it caps the first phalanx; or the fingers and toes may be- 
come the seat of gangrene, and spontaneous amputation 
may result without pain. 

^VHAT IS THE DIFFERENTIAL, DIAGNOSIS ? 

The diagnosis depends upon the presence of irregular 
anesthetic patches associated with pigmentation and pallor 
of the skin, with muscular atrophy, in a person who has 




Fig-ure 35. 

Anesthetic leprosy. 



252 DISEASES OF SPECIAL NEKVES. 

been exposed to the infection of leprosy. The infiltration 
of the skin of the face, producing the characteristic leonine 
expression, is pathognomonic of the disease. 



WHAT IS THE PROGNOSIS ? 

Grave in all cases. It is usually from three to twenty 
years in developing, and when it manifests itself upon the 
cutaneous surfaces it is usually after considerable nerve 
degeneration has taken place. 



WHAT IS THE TREATMENT ? 

The same as in other forms of multiple neuritis. 



PART VIII. 

FUNCTIONAL NERVOUS DISEASES. 



HYSTERIA. 

WHAT IS HYSTERIA ? 

It is a condition characterized by mental and physical 
ailments which may simulate almost any other disease of 
the mind or body. 

WHAT ARE ITS CAUSES ? 

It occurs most frequently in women, about twenty times 
as frequently as in men, and most frequently in the second 
decade of life, the larger number of cases beginning be- 
tween fifteen and twenty years of age. An hereditary 
tendency to neurotic conditions is present in most 
cases. Physical or mental influences directly deter- 
mine the development of the disease in the individual. A 
sudden fright, deep emotion, unhappy love affair, and some- 
times great intellectual exertion may produce it. Disorders 
of the generative organs, either functional or organic, sex- 
ual excesses, masturbation, secondary stages of syphilis^ 
and tuberculosis are sometimes causes. Organic diseases of 
the nervous system may sometimes develop true hysteria. 



WHAT IS THE PATHOLOGICAI. ANATOMY? 

The pathological changes in this disease are negative 
except when it is complicated with some organic nervous 
trouble. 

WHAT ARE THE SYMPTOMS? 

These may be divided into two classes: continuous and 
paroxysmal. 

(253) 



254 FUNCTIONAL NERVOUS DISEASES. 

Continuous Symptoms. — Mental Symptoms. — These are 
the most prominent: defective will power, loss of self-con- 
trol, inability to resist inclinations, irritable temper, phys- 
ical and mental depression. Self -consciousness controls the 
patient's thoughts and actions. The patient is gratified by 
sympathy, which when given helps on the trouble. Exces- 
sive emotion, which is manifested in laughter and tears 
alternating with each other, on the most trivial occasion 
occurs in mild cases. 

Globus Hystericus. — A sensation of something suddenly 
closing the throat, or of a ball rising from the stomach to 
the throat is a very common symptom. 

Hijperesthesia. — There is hyperesthesia in various parts 
of the body, called hysterogenic spots. They may be up 
and down the spine or in the ovarian region. When these 
spots are irritated by pressure, a true hysterical spasm may 
be induced. They may also be on the breasts or on the 
trunk, and sometimes on the vertex. 

Anesthesia. — This may occur in various forms; the most 
common are hemianesthesia, anesthetic spots, and anesthesia 
of one limb. Hemianesthesia may be extremely profound 
from the top of the head to the sole of the foot, associated 
with vaso-motor changes; the prick of a pin will not. cause 
bleeding. It may change from one side to the other. 

Hyperalgesia — Is present as a severe neuralgic pain in 
the breast, or as mastodynia. 

Amaurosis. — This is rather a rare condition, coming on 
suddenly and disappearing suddenly. It may, however, last 
for some time; months or even years. 

Amblyopia^ Achromatopsia^ Dyschromatopsia. — Any one 
of them may be present. 

Deafness. — It is common and may come on suddenly and 
be complete. It may occur with hemianesthesia or alone. 

Anosmia. — Presents in most cases of hemianesthesia. 

Paralysis. — It may exist in various forms. There may 
be a monoplegia, paraplegia or hemiplegia, or it may be con- 
fined to a few muscles, such as are affected in some forms of 
facial paralysis. Paralysis of the muscles of the tongue, 
larynx, pharynx, and esophagus may also be present. There 
may be only a slight loss of power or complete palsy. It 
may come on suddenly or develop gradually and gradually 



FUNCTIONAL NJERVOUS DISEASES. 255 

grow worse. It may last for only a short time or even for 
several years. The paralyzed parts become blue and mot- 
tled, and there may be hyperesthesia of the paralyzed limb. 

Contractures. — They are present in some cases, and they 
may come on suddenly or gradually; most often suddenly. 
They do not relax during sleep, but may relax under chloro- 
form. There may also be present anesthetic or hyperesthetic 
areas in the contracted limb. 

Tremor. — It is a most important symptom, and is gen- 
erally caused by trauma or some toxic agent, such as alcohol 
or lead. It may be persistent and last for a year or two. The 
oscillations may be rapid, medium or slow. 

Inco-ordination. — Hysterical ataxia has been known as 
astasia-abasia, which is a loss of the power of standing and of 
walking. When the patient is lying or sitting there is full 
muscular power in the legs, or he may be able to walk upon 
all fours, but is not able to walk properly. 

Atrophy. — It may occur in limbs which are paralyzed 
and contracted or anesthetic. 

Vomiting — Is sometimes extremely frequent, but is 
usually dominated by the mental state. 

Anorexia. — Anorexia may persist for months, giving us 
examples of the so-called ''fasting girls." 

Heart. — The action of the heart may be slow, quick, or 
irregular, unassociated with dyspnea. 

Fever. — It may be continuous, intermittent, or remit- 
tent. 

Cough. — It may be a persistent and troublesome symp- 
tom. 

Aphonia. — Aphonia may be present and last for years, 
the voice being completely lost. 

Phantom Tumors. — Phantom tumors of the abdomen oc- 
casionally occur. They may simulate pregnancy, and even 
be accompanied by enlargement of the breasts. They may 
appear with great rapidity and disappear gradually. 

Anurea. — This occasionally occurs but is not a common 
symptom. 

Paroxsmal Symptoms. — Convulsions. — These are usually 
preceded by a period of unrest and ill-feeling, with mental 
symptoms similar to those described above, for some time 
before the attack. Tears and laughter are excited readily, 



256 FUNCTIONAL NERVOUS DISEASES. 

hallucinations and delusions are common, or there may be 
disorders of the digestive apparatus. The fit is ushered in 
by an aura, such as globus hystericus, or circumscribed pain 
in the head of very limited extent, with a feeling as if a nail 
were driven into the head; or there may be extreme sensi- 
tiveness of one of the hysterogenic spots. The convulsion 
may be divided into four periods : 

The epileptoid, in which the arms and legs are usually 
extended, hands clinched, trunk bent, usually opisthotonos, 
eyes crossed, and the teeth set; breath is arrested, pulse ac- 
celerated, and consciousness lost. When falling, the patient 
does not usually hurt herself and the tongue is not bitten. 
Tonic spasm is followed by a clonic stage which lasts for a 
little while and then gradually subsides. 

The period of grand movements or clownism, which is 
characterized by violent and extravagant muscular move- 
ments. The patient's body may assume the so-called arc of 
a circle, which is a position of complete opisthotonos; or 
there may be rapid flexing and extending of the limbs in 
various ways. There is not usually loss of consciousness 
during this second period. 

The passionate period is a period of passionate attitudes 
which are simply expressions of the mental condition. 
There may be different attitudes assumed, such as that of de- 
fense, menace, appeal^ ecstasy, scorn or lamentation. 

The period of delirum, which is really a period of emo- 
tional disturbance, continuous with that of the first period 
but not characterized by active motions. The delirium 
may merge into obstinate silence. This hysterical convul- 
sion may last from the first to the fourth stage, from one- 
quarter to one-half an hour, but the fourth stage may last 
for a day or two. The attack may pass off with a profuse 
flow of limpid urine, and the patient after a time be herself 
again. 

Lacunae of memory or periods of loss of memory are fre- 
quent after the paroxysms, or may take the place of the 
real hysterical convulsion. During these lapses of memory, 
the patient is not able to realize her surroundings or just 
who she is, and after the lapses are over she cannot recall 
what has occurred during these times. 



FUNCTIONAL NERVOUS DISEASES. 257 

SomnamhuUsm. — This is a common symptom in hys- 
terical subjects. 

Catalepsy. — This is a condition of both mental and 
motor inertia. The thoughts as well as the limbs remain 
in any position in which they are placed. The limbs may 
remain rigid for a long period of time. 

Lethargy. — The patient lies in a sort of stupor with 
closed eyes. There may be fibrillary tremors of the eye- 
lids. This condition may last for hours. 

Trance. — A higher degree of lethargy. It is a condition 
of suspended cerebration, and may last for days. 



WHAT IS THE DIFFERENTIAL, DIAGNOSIS ? 

The diagnosis depends mainly upon the changeability 
of the symptoms, and, as the definition implies, it is the 
fact of simulation of so many diseases that enables us to 
make the diagnosis. The main point to be determined is 
the presence or absence of organic changes, and when that 
has been determined the diagnosis is easy. The symptoms 
of hysteria coming on after great mental excitement would 
lead us to a diagnosis. 

WHAT IS THE PROGNOSIS ? 

The prognosis as to recovery depends upon the cause 
and surroundings of the individual in each particular case. 
Some cases get well very soon, and others may persist for 
years, there being absolutely no way to determine the out- 
come. It does not usually produce death, but organic 
changes may supervene as the result of hysteria and prove 
fatal. 

WHAT IS THE TREATMENT ? 

GrENERAL. — Avoid those causes which may produce the 
disease, such as great mental emotion, late hours, or any- 
thing which is likely to draw heavily upon the vital forces; 
but more than all, a firm yet kind and sympathetic hand 
should control the case. In no disease is firmness on the 
part of the physician and persons who come in contact 
with the patient so necessary as in this. Extremely severe 
measures have to be used sometimes, such as confining the 
patient to her room, or even threatening with severe meas- 



258 FUNCTIONAL NERVOUS DISEASES. 

ures, such as cauterization of the back. The object of these 
measures is to stimulate the patient to such a degree that 
she will endeavor to get control of herself and prevent the 
disease from manifesting itself. During the convulsion 
simply watch the patient to see that she does not harm 
anyone. Have the clothing loosened so that there may be 
free action of the respiratory muscles. 

Remedial. — Agnus castas. — Hysteria with maniacal las- 
civiousness; despairing sadness; peevish; inclined to be 
angry; nervous weakness; lethargy; frenzy; sleeplessness, 
or starting up frightened in her sleep. 

Anacardium. — Restlessness; must be in constant mo- 
tion; feels as if she had two wills, one commanding to do 
what the other forbids; great f orgetf ulness ; constant de- 
sire to urinate; urine clear as water. 

Asafetida. — Where the hysteria is the direct result of 
the checking of habitual discharges; globus hystericus; 
flatus accumulates in abdomen, and pressing up against the 
lungs caiises oppression of the chest; sensation as if a ball 
started in the stomach and came up into the throat. 

Cactus, — Sadness, crying without reason, consolation 
aggravates, love of solitude, fear of death, whole body feels 
as if caged in wires. 

Gelsemium. — Hysterical convulsions with spasms of the 
glottis; hysterical epilepsy; excessive irritability of mind 
and body with vascular excitement; semi-stupor with lan- 
guor and prostration. 

Ignatia. — Perversion of the co-ordination of functions; 
disposition to grieve, to brood in melancholic sadness over 
real or imaginary sorrows; mental symptoms change often; 
cheerfulness, then great despondency. 

Moschus. — Hysterical paroxysms with insensibility ; cries 
one moment and bursts into uncontrollable laughter the 
next; palpitation of the heart; tremulousness; fainting 
spells, especially as soon as the eyes are closed, with pale 
face and coldness; rush of blood to head, with staring eyes; 
suffocative constriction in chest; copious, pale urination. 

Platina. — Demonstrative self -exaltation and contempt 
for others; cramp pain in the forehead as if between screws; 
great alternation of sadness and cheerfulness; apprehension 
of death with disposition to weep. 



FUNCTIONAL NERVOUS DISEASES. 



259 



PidsutiUa. — Constriction in throat; feels something in 
throat impeding speech, especially at night in bed; con- 
stant change in her feelings and in her symptoms; profuse, 
watery urine; tendency to weep; craves sympathy. 



EPILEPSY. 



WHAT IS EPILEPSY ? 



It is a disease characterized by convulsions or sudden 
loss, or impairment, of con- 
sciousness, in which the con- 
vulsions are not due to or- 
ganic disease or reflex irrita- 
tion, or abnormal blood 
states. 




What are the causes of 
epii.epsy ? 

After one attack has oc- 
curred without any discov- 
erable cause other attacks 
come on very readily. Fe- 
males suffer more frequently 
than males. An inherited 
tendency is sometimes found. 
Defective development of the 
brain may produce a tend- 
ency toward the disease. 
Three-fourths of the cases 
begin under twenty years of 
age, and about one-half of 
them between the ages of ten 
and twenty. After thirty years of age males suffer more fre- 
quently than females. As to immediate causes, great mental 
emotion, fright, excitement and anxiety are potent causes. 
Blows or falls upon the head, exposure to the heat of the 
sun, acute specific diseases, intestinal worms, masturbation, 
delayed menstruation at the time of puberty, and syphilis 
may all produce the disease. 



Figure 36. 
Facial expression in case of epilepsy 
of six years' duration. Age, twenty-one 
years. 



260 



FUNCTIONAL NEEYOUS DISEASES. 



AVHAT IS THE PATHOLOGICAL, ANATOMY ? 

In mild cases there is nothing to be seen upon a careful 
examination. In chronic cases there may be some thicken- 
ing and opacity of the membranes of the brain, or there 
may be signs of meningitis. Where the patient has died 
during a fit there is generally intense venous congestion, 
but there are no organic changes. 



W^HAT ARE THE SYMPTOMS ? 

There are two classes of symptoms: major or severe, and 
minor or slight; or, as they are called by some authors, 
grand mal and petit mal. 

Aurm. — They are usually present just before the attack 
comes on. They may consist of numbness in one of the 

fingers or in one part of 
the body. General tremor 
or shivering is an occa- 
sional warning, or there 
may be sensations of pain 
in the epigastrium associ- 
ated with nausea, or sensa- 
'tions of giddiness, also as- 
sociated with nausea. Fear, 
or a vague, dreamy state, 
indescribable smells, sour 
or bitter taste, sudden loss 
of hearing, sudden loss of 
sight, or the appearance of 
objects before the eyes are 
various forms of aura 
which are sometimes pres- 
ent. 

Epileptic Cry. — The so- 
called epileptic cry some- 
times occurs at the onset of the attack. It is a weird kind of 
scream which is a sort of prolonged groan, not very loud, 
but unmistakable when it has been heard once. Some 
patients may commence running just before an attack, or 
will suddenly turn around when walking and go the other 
way. Palpitation and pain in the region of the heart, or 
sudden dyspnea may occur in others. 




Figrure 37. 

Same patient four years before. 



FUNCTIONAL NERVOUS DISEASES. 261 

Grand Mai. — At the onset of the convulsion tonic spasm 
commences, with rigid, violent muscular contractions of the 
limbs, the face is distorted, and while the color may be un- 
changed at first, it quickly becomes pale, then flushed, and 
later livid, as the movements of respiration are interfered 
with. The eyes may be opened or closed, and the pupils 
dilated, as the cyanosis comes on. After a moment or two 
the spasms become clonic in character, and the limbs jerk 
violently. After the spasm is at an end, the patient lies 
unconscious and sleeps heavily for a time, and later can be 
aroused. The convulsions may begin in one part of the 
body, as the face or arm, and then spread to the other parts 
on the same side, finally involving the whole body. The 
patient froths at the mouth and bites the tongue. Urine 
and feces are occasionally passed during the convulsion. 
The attacks of grand mal are sometimes followed by vom- 
iting. 

Petit Mal. — The patient suddenly stops his occupation, 
stares vacantly about him for a moment, and then goes on 
with his work as if nothing had happened. He does not 
fall; has no convulsions; simply a loss of consciousness for 
a few seconds. 

Dual Consciousness. — It may occur in cases suffering 
from grand mal or petit mal. It is a condition in which a 
patient seems to pass from one existence into another. 
When in the abnormal condition he knows nothing of his 
previous normal condition; and when in the normal con- 
dition knows nothing of the abnormal condition. These 
periods of abnormal states may last for hours, days, or 
Aveeks. 

Hystero-Epilepsij. — This is a combination of hysteria and 
epilepsy, but it is a very rare condition. It usually com- 
mences with a true tonic convulsion, followed by clownish- 
ness instead of the sleep which is natural in epilepsy. 

Frequency of Attacks. — In the beginning the patient 
may have severe attacks only once a year, and then in six 
months, gradually increasing in frequency until they may 
come every day or two, or three times a day. 

Condition of Patient between the Attacks. — He may feel 
perfectly well after an attack and until within a few days 
of another attack, when symptoms of approaching illness 



262 FUNCTIONAL NERVOUS DISEASES. 

may manifest themselves, to be dispelled again by the 
attack. 

Mental State. — In severe cases there is a gradual deterior- 
ation of the mental faculties, slight in some, but grave in 
others. Loss of memory, irritablility, inability to concen- 
trate the mind, fits of anger amounting, sometimes almost 
to true mania, and loss of moral sense take place in these 
cases. 

Physical Conditions. — The patient is usually physically 
deteriorated, unable to undergo much exertion, feels more 
inclined to keep quiet and do nothing, becomes pale and 
anemic, and loses appetite and flesh. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The aura, the epileptic cry, sudden loss of consciousness, 
tonic convulsions, biting of the tongue and evacuation of 
the bladder make the diagnosis easy. 

In hysteria there is usually some emotional cause for the 
convulsion, and there is never evacuation of the bladder, 
and no biting of the tongue. 



WHAT IS THE PROGNOSIS ? 

The disease undoubtedly shortens life to some extent, 
but patients may live to the age of forty or fifty. About 
ten per cent, suffer from dementia in the terminal stage. 
Attacks of grand mal may occur so quickly, one after 
another, that the patient passes into a condition called 
" status epilepticus " which usually ends fatally. Epileptics 
very frequently suffer from phthisis. The prognosis is bet- 
ter if all the fits occur in the night, nocturnal epilepsy; or 
if all of them occur daring the day; but at the best it is a 
disease which is difficult to cure. 



WHAT IS THE TREATMENT? 

General. — Any of the causes which may have produced 
the disease, such as masturbation, great mental emotion, 
excitement, or anxiety, should be removed as far as possible. 
Moderate exercise, both of mind and body, is good. The 
patient should have plenty of sleep and avoid what may be 
a source of drain upon the vital forces, 



FUNCTIONAL NERVOUS DISEASES. 263 

Surgical. — If the seizures always commence in one ex- 
tremity, passing to the others later, the epilepsy may be 
clue to irritation over the motor area of the brain which 
controls the part in which the spasm first commences. 
Under such conditions surgical measures may be used to 
advantage, such as trephining and removing some irritating 
growth or depressed bone, or trephining alone may relieve. 

Dietetic. — These patients should be well fed, but must 
eat only digestible food and have their meals at regular 
intervals, the principal one in the middle of the day. Chil- 
dren will sometimes improve rapidly upon only a vegetable 
diet, or a diet of which milk, bread and butter, rice pud- 
ding, corn starch, and Indian meal pudding form the basis. 

Remedial. — Amijl nitrite. — Muscular twitching in legs, 
arms and face, followed by unconsciousness; haunted many 
times a day by an indescribable dread and sensation of the 
coming fit; profound and repeated yawning during uncon- 
sciousness; succession of fits with increasing frequency; be- 
fore one fit ceases another begins. 

Artemisia vulgaris. — Vexed, irritable, depressed during 
the day before a fit at night; fits brought on by violent 
emotions, especially by fright; paroxysm usually followed 
by sleep; mental powers gradually become extinct; petit 
mal; patient is unconscious only for a few seconds or min- 
utes, and then continues his occupation unconscious of 
anything unusual having happened. 

Belladonna. — Fresh cases of epilepsy, with decided brain 
symptoms; aura as if a mouse were running over an ex- 
tremity, or illusions of sight or hearing; convulsion comes 
in upper extremities and extends to the mouth, face, and 
eyes. 

Bufo. — Aura starts from sexual organs or from solar 
plexus ; epilepsy from onanism ; longs for solitude to give 
himself up to his vice; epileptic aura, from uterus to 
stomach. 

Calcarea carbonica. — Epilepsy at the age of puberty or 
from irregular menstruation; irritation of the sexual organs ; 
child masturbates; enfeebled memory; stupid; peevish in 
the intervals between the attacks. 

Cuprum metal lieu m.— Nocturnal epilepsy, or when fits 
return at regular intervals, beginning with sudden scream; 



264 FUNCTIONAL NEEVOUS DISEASES. 

convulsions commencing in the fingers or toes, or in the 
arms, with coldness of the hands and feet; clinching the 
thumbs; suffocative paroxysms; frequent emissions of urine; 
during dentition or from a retrocession of exanthema. 

Hydrocyanic acid. — Recent cases;, sudden complete loss 
of consciousness; extreme coma for several hours; jaws 
clinched; teeth firmly set; frothing at the mouth; inability 
to swallow; hands clinched; stiffness of legs. 

Nux vomica. — Epilepsy from indigestion; aura starts in 
epigastrium and spreads upwards; sensation of ants crawl- 
ing over the face; involuntary evacuation of bladder and 
bowels. ' 

Silica. — Nocturnal epilepsy; spasm occurring about the 
time of the new moon; feeling of coldness before the attack ; 
violent screaming and groaning; warm perspiration and 
sleep after the spasm. 

Stramonium. — Jerking the head continually to the right; 
continued rotary motion of the left arm; deep, snoring 
sleep; pale face; afraid of being alone; convulsions affect- 
ing the upper extremities more than the lower; sudden loss 
of consciousness while reading. 



CHOREA, ST. VITUS' DANCE. 

WHAT IS CHOREA? 

It is a condition characterized by irregular jerking and 
inco-ordinate movements. 



HOW MANY KINDS OF CHOREA ARE THERE? 

Five. Common chorea or Sydenham's chorea ; hereditary 
chorea or Huntington's chorea; habit chorea; saltatoric 
spasm; and electrical chorea. 

WHAT ARE THE CAUSES OF COMMON CHOREA ? 

It occurs most frequently between the ages of five and 
fifteen, but also occurs in adult life. It may occur in all 
climates and in all seasons of the year. Fright or some great 
emotional disturbance, mental worry, acute rheumatism, in- 
fectious fevers, over- study, intestinal irritations, such as 
worms, anemia and mal-nutrition may be exciting and pre- 
disposing causes of the disease. 



FUNCTIONAL NERVOUS DISEASES. 265 

WHAT IS THE PATHOI.OOICAI. ANATOMY ? 

There is usually an intense hyperemia, with dilatation 
of the vessels, minute hemorrhages and softened areas with- 
in the cortex of the brain. In long-continued cases there 
are fibrinous deposits in the walls of the heart. The pyra- 
midal tracts, the lenticular nuclei, and even the spinal cord 
may take on changes which occur in the cortex. 



WHAT ARE THE SYMPTOMS ? 

It may begin suddenly or come on gradually. 

Choreic Movements. — There is first an irregular twitching 
of the hand or face on one side. There are also winking of 
the eye and twitching of the mouth. The child drops things 
from the hands. A little later the child stumbles in walking. 
In three or four weeks the disease may reach its height, and 
irregular movements of the hands and feet, or even of all the 
upper and lower extremities, and perhaps the trunk itself, 
may be involved in continuous and irregular movements. 
Walking is extremely awkward and difficult. The patient 
cannot dress himself on account of inability to control the 
movements of the hands. Speech becomes indistinct be- 
cause of the inco-ordination of the muscles of the tongue. 
Respiration also becomes irregular. These choreic move- 
ments occur both when the muscles are at rest and during 
action, but cease when the patient is asleep. The child is 
usually worse in the morning, but improves as the day ad- 
vances. Excitement and physical exertion aggravate the 
movements. 

Muscular Weakness. — The limbs become weak in a little 
while, but are never completely paralyzed. Nocturnal 
enuresis is usually present. 

Reflex Action. — It is diminished, and in many cases lost. 

Electrical Irritabilitij. — Electrical irritability of the 
muscles is increased in most cases. 

Mental Conditions. — The mind is usually dulled, the 
patient becomes irritable, peevish, and hard to please or 
manage. Excessive mental excitement and even delirium 
may occur in severe cases, and sometimes constitutes the 
so-called maniacal chorea, or chorea insaniens. 

General Symptoms. — Loss of appetite, constipation, loss 
of flesh, and general anemia take place after the disease 
has continued for a little while. 



266 FUNCTIONAL NERVOUS DISEASES. 

WHAT IS KNOWN OF HERIDITARY CHOREA ? 

It occurs between thirty and fifty years of age without 
any known cause, beginning first with twitchings in the 
face which gradually extend to the arms and legs. There 
is a slowly progressing mental deterioration with melan- 
cholia, and finally dementia. It is slow in its progress, 
lasting ten or twenty years. It is usually directly heredi- 
tary from either father or mother, more often the latter. 



WHAT IS HABIT CHOREA «? 

It is some special movement or habit which a patient has 
acquired, perhaps early in life, and which continues through 
life. It may be only a shrug of the shoulder or a sniff, or 
the twitching of the eyes, or a sudden bending back of the 
body. It never becomes excessive and causes but little 
trouble. 

WHAT IS SAI^TATORIC SPASM ? 

It is a condition in which there is rapid and violent con- 
tractions of the flexors and extensors, or the muscles of the 
entire leg when the patient attempts to stand, so that there 
is a jumping and springing upward. It only occurs when 
the patient attempts to stand^ and the patient may be 
thrown to the floor. The disease may last only for a short 
time or for many years. It has sometimes occurred in epi- 
demics in Russia, Canada and Java, and has been called the 
"jumping sickness." 

WHAT IS EI.ECTRICAT, CHOREA ? 

It is a disease in which muscular movements are sudden, 
like a shock produced by a sudden current of electricity, and 
have the peculiar shock-like contractions so produced. These 
movements usually commence in the arm, spread to the leg 
on the same side, and lat^ involve the other side of the 
body. They gradually increase in severity, and after a time 
the limbs become weak and atrophied, until finally paralysis 
of the whole body comes on. The patient usually dies from 
the paralysis. 

AVHAT IS THE DIFFERENTIAI. DIAGNOSIS OF CHOREA? 

The disease is easily diagnosed by the irregular twitch- 
ing movements which occur while the muscles are at rest or 



FUNCTIONAL NERVOUS DISEASES. 267 

ill action, but cease when the patient is asleep. There is 
usually no difficulty in recognizing the disease. 



WHAT IS THE PROGNOSIS ? 

Attacks may come on and last for a few weeks or for 
several months. Most cases get well after a while, but 
there may be frequently recurring attacks which gradually 
diminish in frequency and severity. In adults it sometimes 
lasts many years. It does not seem to shorten life to any 
extent unless the irregular movements become so severe 
that the patient is unable to eat properly or to rest, which 
causes extreme inanition. 



WHAT IS THE TREATMENT ? 

General. — Mental and physical exertion and emotional 
excitement should be avoided as far as possible. These are 
most important conditions to observe, because any of them 
may produce and keep up the disease if allowed to continue. 
If the disease be severe the patient should be kept in bed 
for a- long time, as complete rest is absolutely necessary. 
The mental condition of the patient should be carefully 
looked after, for the depression is sometimes so great that 
the beneficial effect of rest in bed is neutralized by it; 
and therefore a certain amount of mental diversion should 
be indulged in, such as being read to or listening to music. 
Care should be taken that the patient does not harm himself 
by hitting his hands or any part of the body against hard 
substances, or by falling against anything. It may be 
necessary sometimes to keep the patient in a padded room. 
Severe cases should never be allowed to feed themselves, be- 
cause they may do great harm with the fork or spoon with 
which they break their food. 

Dietetic. — Plain, nutritious food and in sufficient quan- 
tity should be given. 

Remedial. — Agaricus. — Twitching and spasm of the 
eye-balls and eyelids; spasmodic motions, as jerks of single 
muscles or of an upright and lower left extremity; jerking 
of head and neck, with difficulty of swallowing; weakness 
and coldness of limbs and unsteady walk. 

Belladonna. — Reflex chorea from dentition or pregnancy; 
motions of body are generally backwards, or to and fro, bor- 



268 FUNCTIONAL NERVOUS DISEASES. 

ing the head in the pillow; grinding of teeth; after fright 
or mental excitement; dull, heavy, drowsy and stupid. 

Calcarea carhonica. — Fright followed by trembling mo- 
tions of upper and lower limbs; patient low-spirited and 
peevish; cannot speak as he bites his tongue w^hen trying 
to speak; great weakness. 

Crotaliis. — Chorea, especially when it can be traced to a 
septic or toxemic cause, or when occurring in rheumatic or 
albuminuric subjects; starting, jerking, trembling and un- 
steadiness of the limbs; irritable, cross, infuriated by least 
annoyance. 

Ignatia. — Emotional chorea, especially from grief or 
fright, with sighing and sobbing; vacillating gait; stum- 
bles and falls over small objects. 

Laurocerasus. — Emotional chorea after fright; fearful 
contortions and jactitations when awake; restless sleep; 
violent and destructive motions; can neither sit, stand, nor 
lie down on account of incessant motions; speech indistinct; 
tears clothing; strikes at everything. 

Mijgale. — Arms and legs in constant motion; unable to 
dress without assistance; mouth and eyes open and shut in 
rapid succession; when attempting to control the move- 
ments he loses his breath. 

Natrum murkdicum. — Chronic cases when due to fright 
or suppression of eruptions on the face; paroxysms of 
jumping high up, or mere jerking of the right side and 
head. 

Stramonium. — Saltatoric spasm; movements character- 
ized by great violence, affecting the whole body and produc- 
ing the most grotesque leaps; motions and gestures, rotates 
the arms and clasps the hands over the head ; full of fear. 

Tarentula. — Nocturnal chorea; movements do not cease 
even at night; continual motion and trembling of the 
whole body; cannot speak, swallow, sit, stand or walk; fear 
of impending death; is made better by diversion and by 
music. 

PARALYSIS AQITANS— SHAKING PALSY. 

WHAT IS PARALYSIS AGITANS ? 

It is a condition characterized by muscular weakness 
and tremor. 



FUNCTIONAL NERVOUS DISEASES. 269 

WHAT ARE ITS CAUSES ? 

It is more frequent in men than in women. It generally 
commences after forty years of age, and most of the cases 
begin between fifty and sixty. The most frequent causes 
are great mental emotions, physical injury, acute diseases, 
prolonged anxiety and sudden alarm. Physical injury with 
sudden alarm is the most frequent cause. 

WHAT IS THE PATHOLOGICAL ANATOMY? 

Enlargement of the nerve cells within the pons, thick- 
ening of the bloodvessels, induration of the pons, medulla 
and cord, and increase of the connective tissue in the motor 
tracts and nerves. 

WHAT ARE THE SYMPTOMS? 

Tremor. — Usually commences in the hands, sometimes 
in the forefinger and thumb, or it may be in the arm or 
shoulder. It slowly spreads from the part in which it com- 
mences to neighboring parts until one side of the body is 
affected, and then it spreads to the other side. It is an 
alternating contraction of opposing muscles, causing rythm- 
ical motions of the parts to which they are attached. The 
muscles of the trunk, especially those of the back, are some- 
times involved, but the head usually escapes. The tremor 
is the same whether the muscles are at rest or not. It may 
sometimes be controlled slightly by the voluntary action of 
the patient. The muscles of the tongue are sometimes af- 
fected and the jaws later. 

Muscular Weakness and Rigidity. — They come on to- 
gether and are as much symptoms of the disease as tremor. 
The loss of power at first is only slight, but gradually in- 
creases until the patient is unable to grasp anything in his 
hand or to rise from his seat, though paralysis is never com- 
plete. When the patient attempts to make a motion of any 
kind, it is not only weak but it is slow, and it takes some 
time to perform even simple movements. The limbs gradu- 
ally become rigid and assume certain positions, the fingers 
are slightly flexed at all the joints, the arms are flexed at 
the elbows, the body is bent forward, and there is slight 
flexion of the hip and knee-joints. The head is usually car- 
ried forward in the same direction as the body. 



270 



FUNCTIONAL NERVOUS DISEASES. 



Gait. — The patient when starting to walk stands first 
with his body bent forward, his knees flexed; then puts 
one foot a little in advance of the 
other and steps forward slowly at 
first, but after a few steps goes faster 
and then faster until there is a de- 
cided running gait manifested, which 
is called festination. There is also 
a tendency for the body to fall for- 
ward when walking, which is called 
propulsion. The patient seems to 
be running in order to keep his cen- 
tre of gravity. He cannot step sud- 
denly, for if he did he would be likely 
to fall. The tendency to walk rapid- 
ly backward is called retropulsion. 

Myotatic Irritahilifi). — This is 
usually normal. The knee-jerk is 
also normal in the majority of cases, 
but sometimes is increased. 

Sensory Symptoms. — Sensibility 
of the skin is not affected, but there 
may be an aching of a rheumatic 
character in the limbs in those mus- 
cles which afterwards are affected 
by the tremor, particularly in the 
early stages. Great sense of fatigue 
is often felt, and also a great sense 
of heat, which may be in the interior 
of the body or confined to one limb. 

Mental Condition. — The mind is 
usually clear, but the patient is irri- 
table on account of the physical 
restlessness and the mental depression. 




Fignre 38. 

Attitude in paralysis agitans. 



WHAT IS THE DIFFERENTIAL, DIAGNOSIS ? 

The tremor, with the muscular weakness and rigidity, 
usually makes the diagnosis easy. 

It may be differentiated from insular sclerosis by the 
fact of the tremor being present even while the ])atient is 
at rest; while in insular sclerosis it occurs only when the 



FUNCTIONAL NEEVOUS DISEASES. 271 

patient attempts to make voluntary movement, and it is 
more jerky and irregular in character. 



WHAT IS THE PROGNOSIS? 

It is usually unfavorable as far as recovery is concerned. 
The patient may be made better, or the progress of the dis- 
ease may be checked for a long time. There is usually no 
danger of life and the disease may last for many years. 



WHAT IS THE TREATMENT ? 

General. — Freedom from mental or physical exhaustion 
should be had as far as possible. A quiet, regular life and 
freedom from care are necessary. 

Remedial. — Baryta carhonica. — Nervousness; excessive 
irritation of all the nerves; twitches and jerks of the body 
during the day; general weakness of nerves of the body; 
increased weakness; can scarcely put out his arm; general 
paresis and palsy of all the muscles of the body. 

Gelsemium. — Weakness and trembling through the whole 
system; complete relaxation and prostration of the whole 
muscular system; numbness and coldness of the extrem- 
ities; becomes easily tired and exhausted; neuralgic pains 
along the tracts of the nerves; great distress and apprehen- 
sion; jactitation of muscles; tremulous, with profuse urina- 
tion. 

Hyoscijamus. — Not a single part of the whole body nor 
a solitary muscle in a quiet state for a moment; trembling 
of the limbs with weakness; staggering gait; painful numb- 
ness of the hands. 

Mercurius. — Trembling of the hands and tongue; tremor 
of hands so that he cannot lift anything, eat nor write; 
marked tremor of neck and lower extremities; great weak- 
ness and trembling from least exertion; limbs stiff, cannot 
be easily moved; weariness, especially while sitting, as if all 
of his limbs would fall from him; depression of spirits. 

Phosphorus. — Trembling, especially of hands while writ- 
ing; trembling all over the body or in single limbs with 
nervous debility; motions involuntary and uncertain; gen- 
eral relaxation of muscular power; great languor and dis- 
inclination to move; inexpressible heaviness of the whole 
body. 



272 FUNCTIONAL NERVOUS DISEASES. 

Plumhmn- - General debility; restlessness and uneasi- 
ness; tremor with neuralgic pains in the trunk and limbs; 
rapid walk, bending forward; weakness of all the limbs, with 
trembling or numbness. 

Tarentula. — Trembling of the body and limbs; great 
restlessness and agitation; has to change position frequently; 
constantly moving hands, feet and head; least excitement 
irritates; paralysis caused by great mental distress, with pain 
and continual itching in the arms and trembling in the legs. 



TETANUS. 

WHAT IS TETANUS ? 

It is an infectious disease of the nervous system charac- 
terized by tonic spasm of the muscles with marked exacer- 
bations. 

WHAT ARE ITS CAUSES ? 

Trauma, which produces the so-called traumatic te- 
tanus; exposure to cold, producing idiopathic or rheumatic 
tetanus; when occurring in newly-born children it is termed 
tetanus neonatorum; and when occurring after childbirth or 
abortion it is called puerperal tetanus. Tetanus may occur 
at any time during life and is more common in dark-skinned 
races and in temperate regions. The immediate cause of 
the disease is a specific bacillus which produces a toxic ma- 
terial within the system that induces the disease. 



WHAT IS THE PATHOL.OGICAI. ANATOMY? 

The lungs are usually found congested, and there may 
be a hypostatic pneumonia or emphysema. The muscles 
contain small extravasations of blood. There may also be 
rupture of individual fibres. In traumatic cases the wound 
may be in a healthy or unhealthy state, or it may have per- 
fectly healed. In the brain and spinal cord there is disten- 
sion of vessels and minute hemorrhages, undoubtedly due to 
the severity of the convulsions. 



WHAT ARE THE SYMPTOMS? 

Frodrotnal. — In traumatic tetanus in from five to four- 
teen days after the infliction of the wound, but in severe 



FUNCTIONAL NERVOUS DISEASES. 273 

cases from twelve to forty-eight hours, there are noticed 
vague pains in the head and epigastrium, with a general 
feeling of unrest and depression. Sensations of numbness, 
paresthesia, or pain at the seat of the wound will first be 
noticed. 

Trismus or Lock-jaw. — After the prodromal stage has 
lasted for a short time a slight stiffness of the jaws is 
noticed, with some difficulty in swallowing and stiffness of 
the tongue, gradually increasing until the patient is unable 
to separate his jaws. 

Rigiditij of the Neck. — This may come on with the tris- 
mus or precede it. It is noticed first as a slight stiffness 
which the patient thinks is due to having sat in a draught, 
and in the idiopathic cases may be due to this cause. The 
head is slightly bent backward. The stiffness passes down the 
spinal muscles, involving later the muscles of the lower ex- 
tremities. The rigidity is usually tonic, and continues with 
greater or less severity, with exacerbations. 

Opisthotonos.— O^i^ihoiono^ is produced by the severity 
of the muscular contraction of the back, and the patient 
may rest only on his head and heels. 

Pain. — At first the stiffness and rigidity are unaccom- 
panied by pain, but as the spasms increase in frequency 
and severity a cramp-like pain comes on which is intense, 
causing the most agonizing suffering. 

Spasm of Respiratory Muscles. — Fixation of the chest is 
present in some cases and so severe as to suddenly produce 
death from asphyxiation. The muscles of the larynx are 
also involved, complete closure being sometimes produced. 

Spasm of Extremities. — The legs become extended and 
rigid but as a rule the arms are but little affected. 

Temperature. — The body heat is usually somewhat raised 
and in occasional cases may be very high. 

Pulse. — The pulse increases in frequency and is usually 
small 

Mental Condition. — The mind is perfectly clear in all 
cases. 

WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The symptoms of this disease are so peculiar that it is 
not possible to make a mistake in diagnosis except in the 



274 FUNCTIONAL NERVOUS DISEASES. 

very early stages, when rigidity of the muscles of the neck 
may be thought to be due to exposure to cold. But when 
trismus comes on there is no further doubt as to the 
diagnosis. 

WHAT IS THE PROGNOSIS? 

The death rate is very high. When due to trauma about 
ninety per cent. die. In idiopathic cases about fifty per 
cent, are fatal. Fatal cases die in less than a fortnight. If 
the patient survives for two weeks the chances of recovery 
are good. The cause of death is usually asphyxia or heart 
failure. 

WHAT IS THE TREATMENT ? 

General. — The patient should be kept absolutely quiet, 
in a darkened room, and free from noise or worry. Care 
should be taken that he does not hurt himself during the 
intensity of the spasms, and that he does not bite his 
tongue. 

Dietetic. — Liquid food should be given in as large 
quantities as the stomach can bear. If the jaws are set the 
patient may sometimes be fed between the teeth, when they 
are wide apart or when one is missing. It is not well to 
extract a tooth in order to feed the patient because the 
irritation may induce increase of spasm. Nutritive enemata 
of milk and eggs may be given if there is no way of feeding 
by the stomach. 

Remedial. — The use of chloroform is a dangerous pro- 
cedure. While it may relieve for the time being, yet when 
the patient recovers from its effect's the spasm is generally 
increased. The best results can only be had by the use of 
homeopathic remedies. 

Aconite. — Spasm of the eyes; clinched jaws; body 
becomes rigid and bends backward ; limbs distorted with 
spasm; excessive restlessness and tossing about. 

Hydrocyanic acid. — Jaws firmly fixed; lies on bed with 
head fixed and thrown backward; legs fixed and rigid; 
spasm of respiratory muscles; paroxysms come on without 
any apparent cause, dreads their approach, and caiinot 
sleep for fear of the attacks which come on just when he 
is dropping off to sleep; cyanotic appearance; tetanic grin. 



FUNCTIONAL NERVOUS DISEASES. 275 

Ntix vomica. — Jaws rigidly closed; head constantly 
thrown back; violent painful paroxysms in which the limbs 
are extended; body bent like a bow; muscles of chest rigid, 
impeding respiration to such a degree that the face is pur- 
ple at intervals of one-half an hour to an hour; mind per- 
fectly clear; cough between the paroxysms. 

Strychnia. — Pains like electric shocks flash through the 
limbs; tetanic rigidity of the body with opisthotonos and 
trismus, suspended breathing and, finally, paralysis; all the 
senses are acute. 

TETANY. 

WHAT IS TETANY ? 

It is a spasmodic disorder characterized by attacks of 
tonic spasm of the limbs with excessive sensitiveness of the 
motor and sensory nerves. 



WHAT ARE ITS CAUSES? 

Exhausting influences, such as diarrhea, fatigue, the 
results of mental shock and worry, exposure to cold, alco- 
holism, and irritation from intestinal worms. It occurs 
most frequently under three years of age and, again, about 
the time of puberty. 

WHAT IS THE PATHOI.OGIC AL ANATOMY ? 

There is usually a hyperemic condition of the gray mat- 
ter of the spinal cord, and, in children, of the meninges of 
the brain. 

WHAT ARE THE SYMPTOMS? 

It generally begins suddenly with symmetrical tonic 
contractions of the hands, and sensations of numbness and 
tingling in the extremities. At first it is confined to the 
upper extremities, involving the flexors of the forearm, 
hand and fingers, with contraction of the muscles of the 
back and face and of the lower extremities later. These 
spasms may last for a few minutes to hours or days and 
may occur during day or night, sometimes awakening the 
patient from sleep. There is increase of irritability of the 
motor nerves, and if the motor point of a muscle is struck 
there is excessive muscula^r action. Electrical irritability is 
also increased. 



276 FUNCTIONAL NERVOUS DISEASES. 

WHAT IS THE DIAGNOSIS ? 

The disease may be easily diagnosed by the character and 
symmetrical nature of the spasm, with excessive excitability 
of muscles and nerves. 

WHAT IS THE PROGNOSIS? 

Most cases recover, but the disease may continue at in- 
tervals for years. Sometimes only one or two attacks occur 
during the patient's lifetime. 



WHAT IS THE TREATMENT ? 

The remedies may be used that are applicable for te- 
tanus. 

HYDROPHOBIA— RABIES. 

WHAT IS HYDROPHOBIA ? 

It is an acute infectious disease of animals, dependent 
upon an unknown specific poison and may be communicated 
to man by inoculation. 

WHAT ARE ITS CAUSES ? 

As the definition implies, it is due to inoculation of a 
specific virus. It is in most instances communicated to man 
by the bite of a dog; but wolves, cats, horses and other ani- 
mals may be affected and cause it in man. 



WHAT IS THE PATHOLOGICAL, ANATOMY ? 

There is usually considerable congestion of the brain 
and spinal cord, with dilatation of small vessels and an ac- 
cumulation of the leucocyte-like corpuscles around them 
and in the tissues. There may also be clots within the small 
vessels and minute hemorrhages. These changes are most 
common in the cerebral cortex and in the medulla. Myelitis 
is sometimes present, even in acute cases. 



WHAT ARE THE SYMPTOMS ? 



Period of Inoculation. — This may vary. In children it is 
much shorter than in adults. The average period is from 
six weeks to two months or even three months, and some- 



FUNCTIONAL NERVOUS DISEASES. 277 

times a year elapses from the time of the bite until the 
onset of the first symptoms. 

Premonitory Symptoms. — There is first noticed a numb- 
ness or pain about the parts bitten, with loss of appetite, 
depression of spirits, headache, irritability, sleeplessness, a 
sensation of impending danger, and hyperesthesia of all the 
senses. 

Stiffness of the Muscles of the Throat. — Throat rigidity 
with slight difficulty in swallowing may be the first symp- 
tom noticed. The voice is husky. 

Stage of Excitement. — During this stage the active 
symptoms of the disease manifest themselves. There are 
great restlessness and hyperesthesia. The least sound or 
draught of air may produce a violent reflex spasm. There 
is great dread of water and the sight of it will produce a 
spasm. 

Spasm. — This effects particularly the muscles of the 
larynx and mouth, is extremely painful, and accompanied by 
an intense sense of dyspnea. If the patient attempts to take 
water there is a painful spasm of the muscles of the pharynx, 
larynx, and elevators of the hyoid bone. With these spasms 
there may be delirum, hallucinations and delusions, and the 
patient may attempt to injure those about him, and yet will 
try to avoid doing such injury, seeming to be alive to the 
situation. This is the most painful period of the disease. 
The spasms may last for a half a day to a day or two, and 
the mind may be clear when they are present. The spasms 
may involve all of the muscles of the body. 

Paralytic Stage. — Paralysis usually follows the preced- 
ing stage. The patient becomes quiet and unconsciousness 
gradually comes on. The action of the heart becomes weaker 
and death occurs from heart failure. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

There is usually no difficulty in distinguishing hydropho- 
bia from other nervous diseases. 

It is differentiated from tetanus by the length of time 
which occurs after the inception of the bite, and the fear of 
water. 



278 FUNCTIONAL NERVOUS DISEASES. 

WHAT IS THE PROGNOSIS ? 

Usually grave. The inoculations of Pasteur have, how- 
ever, materially changed the prognosis. When possible 
they should be availed of. 



WHAT IS THE TREATMENT ? 

Preventive. — When it is known that a wound has been 
caused by the bite of a dog suffering from rabies it should 
be thoroughly cauterized and made aseptic. Sometimes the 
sucking of the wound, expectorating the saliva, will mate- 
rially decrease the quantity of virus taken into the system. 

General. — When the disease is fully developed the 
patient should be kept in a darkened room and perfectly 
quiet, and anything which may produce the spasm, such as 
a draught of air or any mental excitement, should be guard- 
ed against. 

Remedial. — Belladonna.- — Repeated convulsions and 
horrible spasms with screams and loss of consciousness; 
difficult deglutition; dilated pupils; red or livid counte- 
nance; throwing the body from one side to the other; starts 
in a fright just as he is going to sleep. 

Canfharides. — Convulsions and hydrophobic symptoms; 
any bright light, drinking, or sound of falling water causes 
a spasm; tetanic spasms followed by coma. 

Hijoscyamiis. — Constant state of erethism; not a single 
part of the whole body quiet for a moment; uninterrupted, 
irregular motions full of impetuosity; whole body twisted 
and turned continually; unceasing spitting; frothing at the 
mouth; eyes staring and distorted; suffocative spells. 

Stramonium. — Faintingfits every day; suddenly falls as 
if dead with pale face and almost imperceptible breathing ; 
if disturbed during paroxysm rolls about the floor, becomes 
enraged, and bites those around him ; convulsions* alternat- 
ing with rage; paralysis after convulsions. 



NEURASTHENIA. 



WHAT IS NEURASTHENIA ? 

It is a diminution of nervous energy with increased reac- 
tion, both mental and physical, to external impressions. 



FUNCTIONAL NERVOUS DISEASES. 279 

WHAT ARE ITS CAUSES ? 

Heredity is the most important cause, the parents hav- 
ing suffered from irritability of the nervous system, from 
some organic nervous disease, or from alcoholism. The 
school is responsible for many cases. The child is not prop- 
erly disciplined at home and is over-worked at school. In 
the adult the causes are great mental anxiety, over-work, ex- 
citement, worry, sexual excesses, alcoholic excesses, trauma, 
and the results of typhoid fever, malaria and influenza. 



WHAT IS THE PATHOI.OGICAI. ANATOMY ? 

Changes due to nerve exhaustion involve the nucleus, 
the cell-protoplasm, and even the cell-capsule when it is 
present. There is a marked decrease in the size of the nu- 
cleus and it becomes smooth and rounded. There is also a 
shrinkage in the size of the cell-protoplasm with vacuolation 
for the spinal ganglia. There is usually cerebral hyperemia 
and also hyperemia of the gray matter of the cord. The 
nerve cells easily break down under slight irritation, and 
send out feeble impulses. 



WHAT ARE THE SYMPTOMS ? 

Motor. — Weakness of the legs and back is complained of 
more frequently than weakness of the upper extremities. 
Tremor and exaggerated reflexes are also present. 

Sensory. — There is a vague feeling of distress all over 
the body. The patient feels tired all of the time and be- 
comes easily fatigued. There is also a sensation of light- 
ness or emptiness of the head, and a feeling of uncertainty 
in making voluntary movements. Dizziness, with stagger- 
ing and inco-ordination of movement, is sometimes met. 
Pain in the head, back and limbs, of a dull, diffused charac- 
ter. The headache may be severe and last for days at a time. 
In other cases it may be mild and pass away after the patient 
stops working. Pain in the small of the back with extreme 
fatigue, and aching of the limbs upon slight exertion. 

Spinal Tenderness. — The patient flinches when the sensi- 
tive spinous processes are pressed upon, even slightly. There 
is also a burning sensation down the spine. The sensitive 
spots are not continuous the whole length of the spine, but 



280 FUNCTIONAL NERVOUS DISEASES. 

occur in three or four places. The seventh vertebra, upper 
dorsal and lower dorsal are the points most usually affected. 
Cutaneous hyperesthesia over the back, on the extremities, 
the scalp, face, nipples or testicles may be present. Formi- 
cation and prickling sensations often occur. 

Disorders of SigJit. — The patient cannot use his eyes for 
reading but a short time without suffering fatigue of eyes 
and head. With this vision becomes difficult and the eyes 
become sensitive to light. 

Disorders of Hearing. — Hyperesthesia of the sense of 
hearing is common. Roaring, buzzing, whistling, ringing, 
throbbing or ticking sounds may be brought on by fatigue 
either mental or physical. 

Disorders of Smell. — Excessive sensitiveness to odors is 
a common and uncomfortable symptom. Complete loss of 
smell may be present in some cases. 

Disorders of Taste. — Loss of taste, or food tastes like 
sawdust; or there may be a bitter, salty, or acid taste. 

Psychic Disturbances. — There is a diminished capacity 
for sustained intellectual efforts. Slight use of the brain 
will bring on a sense of exhaustion, or headache, giddiness 
or lightness about the head. It is difficult for the patient to 
concentrate his mind upon any one subject, and there is also 
a dislike for mental work which formerly pleased him. 
Loss of memory; irritability; trifles exciting him to great 
anger; mental depression; lessening of affections for those 
nearest to him; insomnia; fear of darkness, of crowds, of 
being alone, in close places, and of special localities; the 
handwriting becomes jerky and irregular; stammering or 
scanning speech; inability to enunciate words properly, but 
w^hen he attempts to make the effort to speak clearly he can 
do so. Patients are liable to run their syllables, words and 
even phrases . together. There is huskiness of the voice 
after becoming fatigued. 

General Physical Disturbances. — There may be indiges- 
tion, palpitation of the heart, increased or diminished per- 
spiration, increased or diminished quantity of urine, noctur- 
nal seminal emissions, with weakness and irritability of the 
sexual organs. 



FUNCTIONAL NEUVOUS DISEASES. 281 

WHAT IS THE DIFFERENTIAL DIAGNOSIS? 

The diagnosis is usually easy. The symptoms of weak- 
ness which have been enumerated, without the association 
of any organic lesion, will make the case clear. It may be 
differentiated from hysteria by the slowness of onset of the 
symptoms, by the absence of convulsions or anesthesia and 
globus hystericus, and the fact that the symptoms are 
about the same from day to day and do not change from 
day to day as in hysteria. 



AVHAT IS THE PROGNOSIS ? 

This is usually favorable as far as recovery is concerned, 
but some of the cases are long-lasting. If the cause which 
produces the trouble can be removed the recovery is usually 
prompt and rapid. Some patients are confined to bed for 
years on account of the general exhaustion and exacerba- 
tions of pains when moving about. 



WHAT IS THE TREATMENT ? 

General.^ Sometimes a long vacation will stop the 
trouble. At any rate, the patient must decrease his hours 
of work and be relieved from mental anxiety as far as pos- 
sible. Change of scene and travel may sometimes relieve 
the sleeplessness and enable the patient to recuperate. 

Remedial. — Agaricus- — Spinal column sensitive to 
touch; aching along back and limbs; great sexual desire; 
extremities go to sleep easily ; sensation as if a cool current 
of air were passing from the spine all over the body. 

Anacardium. — Sadness; weakness of memory; sensation 
of band around the head; trembling from every motion; 
anxiety when walking as if someone were pursuing him; 
full of suspicion. 

Calcarea carhonica. — Great exhaustion in the morning; 
unable to go up stairs on account of exhaustion and short- 
ness of breath ; he may feel well, but every exertion or ex- 
citement produces exhaustion. 

Gelsemium. — Muscles feel bruised and will not obey the 
will; loss of muscular control; sleeplessness from nervous 
exhaustion; brain-fag; excessive irritability of mind and 
body; dropping of eye-lids. 



282 FUNCTIONAL NERVOUS DISEASES. 

Phosipliorus. — Nervous sensations and weakness; burning 
in small spots along the spine ; stumbling gait from weak- 
ness; involuntary urination from weakness of the sphinc- 
ters; palpitation of the heart. 

Picric acid. — Patient dreads any mental or physical 
work, but improves when warmed up to it; legs tremble 
with great nervousness; feeling of loss of power. 

Zincum. — Neurasthenia with hyperesthesia; burning 
between shoulder-blades and along the whole spine; stiff- 
ness and tension of the neck; frequent jerks in the limbs. 



HEADACHE. 

WHAT ARE THE CAUSES OF HEADACHE ? 

This is a common nervous symptom and may be due to 
many causes. It occurs during all periods of life and in all 
kinds of persons. Women suffer more frequently than 
men, and it is more common in persons living in cities than 
in the country. Those following literary and sedentary 
purciuits suffer more frequently than those following manual 
occupations. Trauma producing' concussion of the brain, 
trauma of the brain, or laceration of brain substance ; pas- 
sive congestions due to pressure about the neck, or tumors 
pressing upon veins of the neck; active congestion from 
prolonged mental or physical strain; the first stages of men- 
ingitis ; the result of the action of certain drugs, as nitrite 
of amyl, alcohol and glonoine; anemia from loss of blood or 
from prolonged mental exertion ; toxemia, such as occurs in 
acute specific fevers, uremia, diabetes, gout, rheumatism, 
lithemia, gastric disturbances; syphilis and its results upon 
the vessels of the brain; organic diseases, as tumors, abscesses, 
aneurisms ; caries of the cranial bones ; reflexes from diseases 
of the eyes, nose and throat, ears, intestinal tract, sexual 
organs; various nervous diseases such as hysteria, epilepsy 
and neurasthenia; and toxic causes, as lead, tobacco, opium 
and chloral, are all responsible for headache. 



WHAT IS THE PATHOLOGICAL ANATOMY? 

In many cases there are no changes evident in the brain. 
When due to organic diseases certain changes are manifest, 



FUNCTIONAL NEEVOUS DISEASES. 283 

It is difficult to determine what is the actual condition 
which produces the pain. Undouhtedly it is an irritation 
of the meningeal nerves which causes it. It is the mem- 
branes and not the brain itself which are chiefly concerned 
in the production of headache. 



WHAT ARE THE PECULIAR CHARACTERISTICS OF HEADACHES? 

It may be pulsating when due to circulatory disturb- 
ances; dull and heavy when produced by toxemia; binding 
or constrictive when occurring in neuropathic conditions, 
such as hysteria and neurasthenia; burning or sore when 
resulting from rheumatism or from gout. The headache 
may be frontal when due to constipation, errors of eye re- 
fraction, or gastric d3^spepsia; on the vertex w^hen due to 
anemia, uterine troubles, or disease of the bladder; tem- 
poral when caused by decayed teeth or inflammation of the 
middle ear; occipital when due to spinal irritation or dis- 
placement of the uterus. 



WHAT IS THE PROGNOSIS? 

The pains may be constant for a day, week, or even 
longer. Some persons suffer continuously for years w^ith 
severe headaches. When due to organic brain disease the 
prognosis of the primary condition will be the prognosis 
for the headache. 

WHAT IS THE TREATMENT? 

General. — When headache is due to gastro-intestinal 
disturbances care in regard to the diet is of the utmost im- 
portance. Prohibition of sweets, indigestible substances 
and stimulants of all kinds should be insisted upon. The 
removal of the cause of the headache when it can be re- 
moved is absolutely demanded. During the attack the 
patient will use his own inclination as to w^hether it is bet- 
ter to keep quiet or move around in the open air. 

Ri&M^EDiAij.--Antimonium cruel iim. — Headache from bath- 
ing or wetting the head or after smoking; rush of blood to 
the head; bursting pains; disordered stoma*ch. 

Arsenicum. — Periodical headaches; brain seems to be 
loose on moving the head; general confusion and heaviness 
in the house; better in the open air; hair falls out; nausea. 



284 FUNCTIONAL NERVOUS DISEASES. 

Baryta carhonica. — Headaches of aged; aggravation after 
walking, eating, or from a warm stove; pressing headache 
just over the eyes; feeling of tightness in occiput; vertigo 
with nausea on stooping. 

Belladonna.— Kighi-^idiQdi headache; throbbing pains; 
cerebral congestion with intolerance of light and noise; hot 
head, cold feet; headache relieved by sitting propped up. 

Bryonia. — Headache begins in occiput or else in fore- 
head, extending into the face or neck; worse from the least 
motion, even from moving the eyeballs or stooping; gets 
sick and faint on sitting up; sour, bitter vomiting; vertigo 
and sensation of fullness in head, worse in the morning. 

Carbolic acid. — Congestive headache; sensation of a band 
around head; extremely sensitive to odors; pain in right 
side of head. 

Carlo vegetabilis. — Frontal headache worse in the morn- 
ing when waking from sleep, having spent the best part of 
the night carousing; occipital headache with bilious symp- 
toms ; humming or buzzing in the head as though a hornet's 
nest were located there; worse in warm room. 

Iris versicolor. — Sick-headache periodically every Sun- 
day; school-teacher's headache; , pains intense, throbbing, 
and preceded by blurred vision, often causing temporary 
blindness; supraorbital headache; vomiting frequent when 
the headache is worst. 

Lachesis. — Left-sided headache, aggravated or caused by 
the heat of the sun; headache at the climacteric period or 
with cold in the head; pains relieved as soon as any sup- 
pressed discharge appears. 

Lycopodium. — Tearing pains back and forth in forehead; 
worse from mental exertion and in the evening; rush of 
blood to the head. 

Niix vomica. — Occipital pains with bilious attack; begins 
in the morning and increases all day until night; sour or 
bitter taste in the month; nausea and vomiting; ineffectual 
retching; accumulation of flatus. 

Platina. — Squeezing headache as if a board were pressed 
against the forehead; pain increases and decreases gradually; 
crampy pains as if squeezed at the root of the nose. 

Sanguinaria. — Violent pains in occiput, extending over 
head and settling over the right eye; cannot bear sound or 



FUNCTIONAL NERVOUS DISEASES. 285 

odors, or anyone walking across, the floor, as the slightest jar 
annoys; must remain in a quiet, dark room; pains so violent 
that she is apt to go out of her head; nausea and vomiting. 
Spigelia. — Pains come from nape of neck and settle over 
the left eye; sick-headache; sensation as if the head were 
open all along the vertex; headache reaches its acme at noon. 



MIGRAINE— SICK HEADACHE— HEMICRANIA. 

WHAT IS MIGRAINE ? 

It is a severe, paroxysmal, periodical pain in the head, 
usually unilateral, and generally associated with nausea, 
vomiting, and disorders of the vision. 



WHAT ARE ITS CAUSES ? 



Some cases begin in childhood and are produced by over- 
work at school. Injury, shock, or exhausting diseases may 
produce the trouble. It may occur frequently in several 
members of a neurotic family. 



WHAT ARE THE SYMPTOMS ? 

There may be a sense of malaise and depression several 
days before the attack, or these symptoms may last only a 
feAv hours before the pain comes on. It usually commences 
in the morning and gradually increases in frequency until 
the patient has to stop his occupation and lie down. The 
pain commences on one side of the head, either in the fore- 
head or occiput, and increases until it finally involves the 
whole head. It is of a throbbing character, increased by 
the slightest noise, light, or jar. There is usually dimness 
of vision or flashes of light before the eyes. Confusion of 
ideas and dizziness are common. At the climax there are 
nausea and vomiting, which sometimes relieve. The face 
is usually pale, the pulse hard and small. These attacks 
may last six, twelve, or twenty-four hours, and even for sev- 
eral days. When the attacks begin to lessen the patient 
falls asleep, and when he awakens he feels much better 
than before the attack. The intervals between the attacks 
vary considerably. Sometimes they occur every week, every 
fortnight, or once a month. 



286 FUNCTIONAL NERVOUS DISEASES. 



WHAT IS THE DIAGNOSIS? 



The periodicity, the method of beginning, and evolution 
of the attack, culminating in nausea and vomiting, make the 
diagnosis easy. 



WHAT IS THE PROGNOSIS ? 



Some cases may continue for years with great regularity. 
As a rule when the attacks become once established they 
persist at varying intervals throughout the patient's life. 
They have no tendency to shorten life. 



WHAT IS THE TREATMENT ? 

The same as that for headache in general. 



NEURALGIA. 

WHAT IS NEURALGIA ? 

It is a functional disease of sensory nerve fibres and char- 
acterized by pain. It may be idiopathic or symptomatic. 

The most common form of neuralgia is that affecting 
the fifth nerve, of which there are two forms ; symptomatic, 
trigeminal neuralgia and tic douloureux or prosopalgia. 



WHAT IS THE PATHOLOGICAL ANATOMY OF NEURALGIA ? 

There is usually a low grade of neuritis, but the nerve 
does not appear to be changed. 



WHAT ARE THE CAUSES OF SYMPTOMATIC TRIGEMINAL NEU- 
RALGIA ? 

It occurs, most frequently in women and more often 
upon the left side. Caries of teeth, malarial poisoning, 
anemia, exposures to cold; frequent pregnancies, eye-strain, 
diseases of the nares, gout, syphilis, diabetes, trauma, rheu- 
matism^ and the great neuroses, hysteria and epilepsy, may 
all be causes of the disease. 



WHAT ARE THE SYMPTOMS ? 

The pains are sharp, shooting, lancinating and intense, 
with periods of exacerbation and remission. There are 
often tender points along the course of the nerve, and over 



FUNCTIONAL NERVOUS: DISEASES. 287 

the parietal eminence and vertex. The pain may extend all 
over the head from the occiput to the frontal region, in- 
volving the ear and orbit. 



WHAT IS THE COURSE OF SYMPTOMATIC TRIGEMINAL NEU- 
RALGIA ? 

It is relieved when the disease which produces it has 
passed away. 

WHAT ARE THE CAUSES OF TIC DOULOUREUX ? 

It occurs most frequently in persons over forty years of 
age, and is usually brought on by exposure, over-work, de- 
pressed mental condition and diseases of the teeth and jaws. 



WHAT ARE THE SYMPTOMS? 

There is intense darting pain, which usually starts on 
the upper lip and on the side of the nose and radiates into 
the eye, to the temple and side of the head, and through to 
the teeth. It is usually confined to one side, and during 
the pain the face is flushed, there is increased flow of water 
from the eyes and nose, and the expression of the patient is 
one of great agony. These paroxysms may last for a few 
moments and then diminish in severity, but do not pass en- 
tirely away. The least draught of air, speaking or eating, 
will bring on a spasm. The pains are usually worse during 
cold weather and cease during summer. 



WHAT IS THE DIFFERENTIAL. DIAGNOSIS OF NEURALGIA ? 

A sharp, shooting, lancinating pain along the course of 
a nerve is characteristic of neuralgia in any part of the body. 

It may be differsntiated from rheumatism by its occur- 
rence only along the course of a nerve. 



AVHAT IS THE PROGNOSIS ? 

The prognosis depends upon the cause; it is usually 
favorable under homeopathic treatment. 

WHAT IS THE TREATMENT ? 

General. — Rest of the part involved is most important. 
Local applications of heat are usually of great benefit. 



288 FUNCTIONAL NER\X)US DISEASES. 

Remedial. — Aconite. — If occurring from exposure to dry, 
and cold winds; violent congestion of face, which is hot, red 
swollen; neuralgic pains in any part drives the patient to 
despair; worse at night; pains burning, lancinating, pulsa- 
ting, tingling and benumbing. 

Arsenicum. — Malarial neuralgia; recurs periodically, 
mostly in the face; little fine burning needles about face, 
following the course of the nerves; burning, tearing pains 
especially at night; great anguish; excessive weakness; 
affected parts feel cold ; worse after prolonged exercise. 

Belladonna. — Right side; paroxysms after gradually in- 
creasing to an intolerable acuteness cease suddenly; lan- 
cinating, burning pains, worse by motion, light, shock, or 
contact; worse from lying down; better by sitting up. 

Bryonia. — Neuralgic pains left side of face and head; 
pressing, tearing, shooting pains; better by hard pressure 
and from cold applications. 

Chininum arsenicosum. — Violent neuralgic pains in left 
mammary region as if it were torn out with a red-hot tongs; 
worse by motion; pains come and go quickly; restless. 

Cimicifuga. — Neuralgic pains in any part of the body 
when reflex from uterine or ovarian disease ; sensation of 
heat on top of the head; feeling as if top of head would 
fly off; sharp, lancinating pains over the eyes; great anxiety 
and nervousness. 

Croton tiglium. — Brachialgia; shooting, tearing pains 
extending the whole length of the limb ; inability to move 
or lie down; the least attempt to stir causes pain; arm be- 
comes paralyzed and feels like a heavy weight. 

Gelsemiutn. — Intense pain in the upper portion of the 
spinal cord and brain, commencing in the occiput, passing 
through the brain, and ending in the forehead and eyeballs; 
better by bending head backward. 

Ledum. — Intercostal neuralgia, especially in axillary re- 
gion; worse from motion; constant chilliness; patient 
morose; painful pressure in both shoulder-joints. 

Spigelia. — Neuralgia begins in back of head and comes 
forward; left prosopalgia with severe burning, sticking 
pains ; neuralgia comes and goes with the sun ; intense ex- 
citement and great intolerance of the pain. 

Sulphur, — Malarial neuralgia occurring mostly in the 



FUNCTIONAL NJEEVOUS DISEASES. 289 

face and resisting other remedies; worse every day at noon 
or at midnight; gradually increasing to its height and then 
gradually decreasing. 

Terebinthina, — Brachial neuralgia mostly evenings and 
during the night in bed until morning; subscapular and 
supra-orbital neuralgia; sudden twitchings of the limbs as 
from electrical shocks; intense pain along the larger nerves; 
numbness of limbs; motion difficult, as it starts or increases 
the pain. 

VERTIGO. 

WHAT IS VEKTIGO ? 

It is a sensation of movement on the part of surrounding 
objects which are really at rest, objective vertigo; or on the 
part of the person himself, subjective vertigo. 



WHAT AKE ITS CAUSES ? 

Cerebral anemia or hyperemia, irritation of the auditory 
nerve, causing true auditory vertigo, occurring as a symp- 
tom in disease of the labyrinth, toxemia as the result of 
gastro-hepatic derangements, valvular disease of the heart, 
neurasthenia, epilepsy, eye-strain, organic disease of the 
brain, and such mechanical causes as swinging rapidly, ro- 
tating motions, or the rolling of a ship at sea. 



AVHAT IS THE PATHOLOGICAE ANATOMY? 

Except in aural vertigo or organic brain diseases there 
are usually no pathological changes. 



WHAT ARE THE SYMPTOMS? 



Dizziness, with partial blindness or wave-like sensations 
before the eyes. In severe cases it is accompanied by nausea 
and vomiting. In mild cases it lasts but a moment or two 
and then passes away. 

WHAT IS THE TREATMENT ? 

General. — Remove the cause if possible. 

Remedial. — Esculus. — Vertigo with sensation of balanc- 
ing in the head; sensation as if intoxicated; dull, stupefy- 
ing headache. 



290 FUNCTIONAL NERVOUS DISEASES. 

Agaricus. — Strong sunshine causes momentary vertigo 
with staggering gait and imperfect vision either for near or 
distant objects; vertigo from mental exertion; tendency to 
fall forward. 

Aloes. — Revolving vertigo aggravated by turning quickly ; 
insecurity in walking or standing; vertigo after dinner. 

Argentum nitricum. — Morning dizziness with headache; 
complete but transitory blindness with nausea and confusion 
of the senses; buzzing in the ears and general debility of 
the limbs. 

Arsenicum. — Vertigo with reeling during a walk in the 
open air, and stupid feeling in the forehead as if intoxi- 
cated; obscuration of sight when raising the head ; nausea 
when in the recumbent position. 

Belladonna. — Vertigo with nausea when waking from 
sleep in the morning after a night of revelry ; dizziness re- 
lieved in the open air. 

^r^om'a. —Vertigo when rising from a chair, disappear- 
ing after walking, with weakness of the limbs. 

Causticum. — Dizziness at stool and after it, with nausea; 
violent dizziness in the morning on waking, with painful 
dullness of the head. 

Cocculus. — Vertigo with flushed, hot face; confused 
feeling in head after eating and drinking. 

Cyclamen. — When leaning against something feels as if 
the brain were in motion or as if he were riding in a car- 
riage with his eyes closed; despondent and irritable. 

Hifdrocyanic acid. — Insufficiency of arterial contraction 
with frequent headaches; stupefaction and falling down; 
sees through a gauze ; can scarcely keep his feet when rais- 
ing the head after stooping. 

Moschus. — Sensation as if he were turned about so rap- 
idly that he perceives a current of air produced by the mo- 
tion; sensation as if falling from a height; vertigo^ on 
moving the eyelids and on stooping, passing away on rising. 



WRY=NECK— TORTICOLLIS. 

WHAT IS WRY-NECK? 

An unnatural position of the head due to contraction of 
the muscles of the neck. It may be a permanent shorten- 
ing of a muscle or simple spasm. 



FUNCTIONAL NEKVOUS DISEASES. 



291 



WHAT ARE ITS CAUSES? 

It may be congenital, due to atrophy of the sterno- 
cleido-mastoid muscle while within the uterus. Delivery 
by instruments may also pro- 
duce it by causing extreme 
traction of the neck. These 
causes produce permanent con- 
traction of the muscle. It may 
also be due to spasm of the 
sterno-cleido-mastoid. 

The simple spasm is caused 
by exposure to cold; falling, 
when the patient strikes upon 
the side of the neck; mental or 
physical shocks; a strain in the 
muscles of tl^e neck may also 
produce it. It occurs much 
often er in women than in men, 
and during early adult and mid- 
dle life. The spasmodic form 
never occurs in children. There 
is usually a neuropathic dispo- 
sition present in the individual. 




AVHAT IS THE PATHOLOGICAL 
ANATOMY ? 



Figure 39. 

Wry-Neck. 



There is evident irritation 
of the spinal accessory nerve, but where that irritation is 
located it may be difficult to determine. It may be in the 
cortex or along the course of the nerve itself. 



WHAT ARE THE SYMPTOMS ? 

Pain in the sterno-cleido-mastoid muscle like that of an 
ordinary stiff neck may be the first symptom, this being soon 
follow^ed by a spasm of the muscle. The head, when one 
muscle is involved, is inclined toward the affected side, the 
chin is raised, and the head rotated to the opposite side. The 
upper fibres of the trapezius muscle are usually affected, 
together with the sterno-cleido-mastoid, and when both 
trapezii are involved the head is pulled backw^ard. 



292 FUNCTIONAL NEEYOUS DISEASES. 

WHAT IS THE PROGNOSIS? 

It does not shorten life but usually progresses to a cer- 
tain stage and then becomes chronic. Sometimes it is cured, 
though rarely. 

WHAT IS THE TREATMENT ? 

General. — Electricity applied to the affected muscles 
may sometimes help to relax the spasm. In the congenital 
form surgical measures may have to be resorted to, such as 
tenotomy and re-section of the nerve. In the spasmodic 
form surgical measures should never be resorted to. 

Remedial. — Aconite. — Drawing in the muscles of the 
neck with tearing pain, worse by moving the neck; pains 
extend down to the shoulder in cases due to cold. 

Arsenicum. — Neck stiff as if bruised or sprained; neural- 
gic pains in left side of neck. 

Belladonna. — Painful swelling and stiffness of neck, 
worse by bending the head backwards; feeling as if the head 
would break when coughing. 

Lachnanthes. — Pain and stiffness in neck, going over the 
whole head when turning the hea4 or bending it backwards; 
head drawn to one side. 

Bhus toxicodendron. — Stiff neck, with painful tension 
when moving, caused by sleeping on damp ground. 



EXOPHTHALHIC GOITRE— BASEDOW'S OR GRAVES* 

DISEASE. 



WHAT IS EXOPHTHALMIC GOITRE? 



It is a disease characterized by enlargement of the thyroid 
gland, protrusion of the eyes and peculiar symptoms about 
the heart. 



WHAT ARE ITS CAUSES ? 



It occurs more frequently in women during early adult 
life, between fifteen and thirty-five. Anemia or general ex- 
haustion of the system in a person of a neuropathic ten- 
dency may produce it. Great physical exertion or depress- 
ing emotions may also be the cause. 



FUNCTIONAL NERVOUS DISEASES. 293 

WHAT IS THE PATHOLOGICAL, ANATOMY ? 

There is a relaxation of the walls of the bloodvessels, 
with cutaneous hyperemia, enlargement of the thyroid 
gland, and deposit of fat within the orbit. Hemorrhages 
and hyperemia of the medulla have sometimes been found. 
There is usually hypertrophy and dilatation of the heart. 



WHAT ARE THE SYMPTOMS ? 

Palpitation of the Heart. — Heart palpitation with pain 
about the heart and shortness of breath may be the first 
symptoms noticed. Upon examination of the heart noth- 
ing can be determined except its rapid action, the pulse 
reaching from one hundred and twenty to one hundred and 
sixty per minute. 

Exophthalmus and Enlargement of the Thyroid Gland. — 
These two symptoms usually come on together a little 
while after the palpitation of the heart has been observed. 
Exophthalmus may not be present in all cases, but enlarge- 
ment of the thyroid is. A thrill is felt in the enlarged 
gland with the pulsations of the heart, and a venous hum 
is sometimes noticed in the neck. As the exophthalmus 
increases the patient is unable to close the lids and the dry 
conjuctiva becomes inflamed. Opacity and ulceration of the 
cornea may ensue. When the patient attempts to look 
downward the upper lid follows the ball. 

Tremor. — This is an almost constant symptom. It is 
usually slight and fine, but may be coarse. The hands 
only may be affected, or the tongue may be involved. 

General Condition. — The patient is usually irritable, de- 
pressed, hysterical, or neurasthenic; insomia is present, as 
well as anemia and emaciation. Intermittent albuminuria 
is often noticed in these conditions. Increase in the quan- 
tity of urine is frequently observed. Profuse sweating upon 
the least exertion often occurs. 



WHAT IS THE DIAGNOSIS ? 

In well-developed cases a diagnosis is easily made. If 
the exophthalmus be not present the increased action of the 
heart, with tremor, sweating, and general nervousness, will 
enable us to diagnose the disease in the early stage. 



294 FUNCTIONAL NERVOUS DISEASES. 



WHAT IS THE PROGNOSIS ? 



A large number of cases improve materially and a few 
get entirely well ; others are not benefited at all. The dis- 
ease may increase rapidly and cause death. 



WHAT IS THE TREATMENT ? 



General. — Rest is of the utmost importance, both phys- 
ical and mental. In severe cases the patient should be put 
to bed and kept there for a month or two or even longer. 
Under any conditions over-exertion, mental excitement and 
worry should be avoided as far as possible. 

Remedial. — Aurum. — Prominent, protruding, staring 
eyes; tensive pressure in the eyeballs; tremulousness; fre- 
quent urination; restlessness and palpitation. 

Belladonna. — Protruding, staring, half-opened eyes; eyes 
shining; violent palpitations, reverberating in head; pres- 
sure in cardiac region. 

Bromium, — Protrusion of eyes; anxious feeling about 
the heart; goitre; sweat from least exertion; emaciation. 

Calcarea carhonica. — Stiffness of eyeballs; inability to 
move the eyes without unplealsant sensations; excessive 
palpitation, with irregular pulse. 

Gelsemium. — Excessive action of the heart; pulse fre- 
quent, soft and weak; great nervous excitement; excessive 
irritability of mind and body; sweating upon least exer- 
tion; sleeplessness; excessive nervous hyperesthesia and 
vascular excitement. 



DIPHTHERITIC PARALYSIS. 

W^HAT IS DIPHTHERITIC PARAI.YSIS ? 

A form of paralysis beginning in the second or third 
week after the disappearance of the throat symptoms in a 
case of diphtheria. 

WHAT ARE ITS CAUSES ? 

It occurs most frequently in aaults, but may occur in 
children, and is due to a toxemic condition produced by the 
diphtheritic poison and affecting the nerves. 



FUNCTIONAL NERVOUS DISEASES. 295 

WHAT IS THE PATHOI.OGICAJL ANATOMY? 

The muscles are usually found normal, but there may 
be granular and fatty degeneration of the fibres. There 
may also be degeneration of the nerves supplying the par- 
alyzed parts, either in the extremities of the nerves or along 
their whole course. It is a simple degeneration, often 
called parenchymatous neuritis. The motor nerve cells of 
the anterior cornua of gray matter of the spinal cord are 
sometimes found swollen and unduly homogeneous and vit- 
reous in aspect; smaller than normal, and with shrunken 
processes. 

WHAT ARE THE SYMPTOMS? 

Paralijsis of the Palate. — This feature is manifested by 
regurgitation of liquids through the nose when attempting 
to swallow; nasal tone of the voice due to shutting off the 
cavity of the nose during phonation; inability to gargle 
the throat; when the patient utters the sound "ah'' the 
palate is not raised. 

Paralysis of the Pharynx. — This symptom is not com- 
mon but sometimes may occur; when present to a great de- 
gree prevents swallowing. It is a serious sign when it does 
occur. The voice is hoarse, food gets into the larynx when 
swallowing, producing coughing and strangling. 

Eye Symptoms. — There is loss of power of accommodation 
of the eye, due to paralysis of the ciliary muscles. Vision 
for distant objects is normal, but is impaired for near ob- 
jects. Both eyes are always affected. Pupils respond slug- 
gishly to light. Divergent squint is often present. 

Paralysis of the Limbs. — Soon after the affection of the 
palate a gradually increasing weakness of the lower extremi- 
ties is observed. The muscles become flabby and without 
tone, the knee-jerk is lost, the legs are moved as if they were 
heavy and limp. These symptoms gradually increase until 
the patient is unable to walk. The arms are also affected to 
a greater or less degree after the lower limbs have become 
involved. 

Sensory Sijmptoms. — Sensations of numbness, tingling, 
pins and needles, and hyperesthesia may last for a time and 
be followed by diminished sensibility, or even complete an- 
esthesia of different parts may be present. 



296 FUNCTIONAL NERVOUS DISEASES. 

Inco-ordination. — Both upper and lower extremities may 
be affected; a condition resembling locomotor ataxia is often 
present. 

The Trunk Muscles. — These are not usually affected, but 
may become so weak that the patient will not be able to sit 
up or turn over in bed. 

Convulsions. — Spasms are sometimes present in severe 
cases. 

TVHAT IS THE DIFFEKENTIAL DIAGNOSIS ? 

Gradually increasing paralysis of the palate and lower 
extremities, coming on two or three weeks after an attack 
of diphtheria with flaccidity of the muscles, will make the 
diagnosis easy. 

WHAT IS THE PROGNOSIS? 

It is usually good unless the symptoms commence with 
great severity, when the disease may prove fatal on account 
of heart-failure. Generally improvement begins in a few 
weeks and in two or three months the patient will have 
entirely recovered. 

WHAT IS THE TREATMENT ? 

General. — The patient should be kept quiet in bed and 
not allowed to make any physical exertion. It is of the ut- 
most importance to keep up the patient's strength, and in 
order to do this liquid food may have to be given by means 
of a stomach-tube, or it may be given by injections into the 
rectum. 

Remedial. — Argentum nitricum. — Paralytic heaviness 
and weakness of the legs with sick feeling, drowsiness, 
chilliness and sickly appearance; limbs, especially the knees, 
start up at night, awakening the patient; legs feel as if 
made of wood. 

Baryta carhonica. — Dragging the thighs, particularly 
when going up stairs on account of paralyzed feeling in the 
middle of the thigh; knees totter when attempting to walk; 
coldness of the feet; burning soreness in the bends of the 
knees; sudden attacks of momentary pains in the limbs, 
with chilliness. 

Causticum. — Hands and feet go to sleep; formication in 
limbs; paralytic weakness and trembling of limbs; intoler- 
able uneasiness of limbs in the evening. 



FUNCTIONAL NERVOUS DISEASES. 297 

Cuprum. — Paralysis of lower limbs; frequent involun- 
tary doubling up of the knees in walking ; tingling in the 
extremities; weakness and weariness of limbs; coldness and 
bluish appearance of extremities. 

Phosphorus. — Paralysis and formication in the extremi- 
ties, w^ith nervous debility ; loss of power over all the limbs, 
especially in the joints as if paralyzed; hands and feet numb 
and clumsy; limbs tremble from every exertion; when walk- 
ing makes missteps from weakness. 

Zincum. — Weakness and weariness of the limbs, with 
trembling upon the least exertion; formication and coldness 
of feet; excessive nervous feeling in feet with constant at- 
tempts to move them; edema of the legs. 

OCCUPATION NEUROSES. 

WHAT ARE OCCUPATION NEUROSES? 

They are certain conditions produced by attempts to per- 
form some oft-repeated muscular action, usually one that is 
involved in the occupation of the sufferer. The most fre- 
quent symptom is spasm in the part, which prevents the in- 
tended action. The various kinds of spasm are writer's 
cramp, piano-player's cramp, telegrapher's cramp, and gold- 
beater's cramp. The most common form is writer's cramp. 



AVHAT ARE THE CAUSES OF WRITER'S CRAMP ? 

It is more common in males because fewer women are 
engaged in writing than men. It occurs during the active 
adult period of life. There is usually a neuropathic tend- 
ency, either hereditary or acquired. Excessive mental worry, 
intemperance, and anything which lowers the vital forces 
may be predisposing causes. Excessive writing is the ex- 
citing cause. 

AVHAT IS THE PATHOLOGICAL ANATOMY ? 

In some forms neuritis is undoubtedly present. In others 
some organic lesion of the brain may be present. 



AVH AT ARE THE SYMPT03IS ? 



There may be: 

( 1). A simple weakness of the muscles of the hand and 



298 FUXCTIOXAL NERVOUS DISEASES. 

forearm, which allows them to become easily fatigued after 
writing a little while. This fatigue will gradually increase 
until it becomes so great that upon continuing the attempt 
to write the arm will fall powerless to the side. This is 
commonly known as pen paralysis or pen palsy. 

(2). The pen may be held in the proper manner and 
the patient feel confident that he will be able to write, but 
the moment he attempts to do so there is a violent trem- 
bling of the hand, and the letters are so shaky that it is 
impossible to decipher them. He grasps the pen more 
tightly, and perhaps uses all the muscular power he has to 
steady his hand, but without avail, and finally gives it up 
from pure exhaustion. This is the tremulous variety, and 
is rarely manifested unaccompanied by spasm. 

(3). After writing for some time a painful sense of 
fatigue is felt in the muscles, accompanied by a dull, heavy 
ache which commences in the fingers, extending to the 
hand, wrist, forearm, and finally passing to the shoulder. 
If writing is persisted in the pain becomes almost unendur- 
able. It is most severe along the course of the median and 
musculo-spiral nerves, with here and there tender points 
exceedingly sensitive to pressure. This is the neuralgic 
form. 

(4)- The patient notices first that after writing a little 
while he unconsciously grasps his pen more firmly than 
usual. At the same time it does not move along as freely 
as it should. The letters become irregular; some are too 
high and others are too low, and the down strokes are 
shaky. The index finger frequently slips from the pen, 
which then falls between it and the second finger. After a 
while the hand, wrist and arm become painfully tired, and 
spasm, tonic in character, supervenes. The is true writer's 
cramp or graphospasm. 

WHAT IS THE DIFFERENTIAL, DIAGNOSIS ? 

The symptoms are usually clear-cut and the disease can- 
not be mistaken for any other. 



WHAT IS THE PROGNOSIS ? 

If taken in the early stage it may be cured, but if al- 
lowed to continue for any length of time it becomes 
incurable. 



FUNCTIONAL NERVOUS DISEASES. 299 

WHAT IS THE TREATMENT ? 

General. — The patient must at once stop writing, for 
if persisted in the trouble will increase steadily. All kinds 
of devices for holding the pen have been invented, but they 
only relieve the trouble for a short time. 

Remedial. — Belladonna. — Heaviness and paralytic feel- 
ing in the arm; spasmodic closing of the fingers; painful 
drawing of the middle joint of the right index finger; 
twitching of the arm. 

Causticum. — Paralytic feeling in the right hand; pain 
in right wrist as if sprained; sensation of coldness in hand 
when grasping anything; painful numbness of thumb and 
index finger, especially when touching something; fingers 
half closed, cannot move them excepting with the other 
hand. 

Cyclamen. — Cramp-like slow contractions of right thumb 
and index finger ; tips approach each other and can only be 
extended by force; numbness in right hand; cannot open 
thumb and index finger. 

Gelsemium. — Tired sensation in the arm after writing, 
steadily increasing; vague pains from tips of fingers to 
scapulae; trembling of hand when attempting to write. 

Niix vomica. — Muscles of fingers and thumb firmly and 
painfully contracted and pressed against the palm so that 
he is unable to open the hand; any attempt to open the 
hand causes severe pain. 

Silica. — Tonic spasm of the hand while writing; cramp- 
like pain and lameness of hand after slight exertion; tear- 
ing pain in wrist and ball of hand, followed by paralysis of 
the hand. 

Stannum. — Cramping of fingers on attempting to pick 
up the pen, or when they have been used a long time fingers 
become suddenly rigid, distorted, spread out, or contracted; 
the spasm can often be ended by opening fingers with un- 
affected hand. 



300 TKOPHO-NEUKOSES. 

TROPHO-NEUROSES. 



RAYNAUD'S DISEASE. 

WHAT IS RAYNAUD'S DISEASE ? 

A variety of dry gangrene described by Raynaud in 1862, 
and characterized as a neuroses dependent on an exaggera- 
tion of the excito-motor nerves. 



WHAT ARE ITS CAUSES ? 

It usually occurs between twenty and forty years of age, 
and twice as frequently in women as in men. Children also 
sometimes suffer. A neuropathic tendency is present in most 
cases. Anemia, chlorosis, malaria, sexual excesses, syphilis, 
menstrual disorders, and exposure to cold may produce it. 
Laundresses often have it, due to the constant emersion of 
their hands in water during wet weather. 



WHAT ARE THE SY3IPTOMS? 

Local Syncope. — There is first noticed a frequent occur- 
rence of coldness, blanching or local syncope, and numbness 
of one or more fingers of the hand or hands which lasts for 
a few minutes, passes away, and is followed by redness and 
burning in the parts first affected. This condition occurs 
with increasing frequency and lasts longer until decided 
changes in the nutrition of the fingers take place. This 
condition is called digiti-mortui, or dead fingers. The fingers 
feel cold to the touch and are pulseless. If they be pricked 
with a needle no blood flows. 

Local Asphyxia. — The tips of the fingers and toes, or the 
parts affected by previous local syncope, assume a bluish- 
black appearance. The nails look as if they had been in 
ink, the fingers and toes become blue and swollen, and there 
may be burning sensations and severe neuralgic pains. 

Local Gangrene. — In this stage small blisters appear on 
the ends of the fingers and toes which fill with blood and 
serum, then dry up, and underneath the scab which forms, 
ulceration takes place. This may heal slowly and a slight 
scar be left. If the gangrenous process be very severe, the 



TR0PH0-XEUR03ES. 301 

skin may become black, dry and shrivelled at tlie ends of 
the fingers and toes. The line of demarcation between this 
and the healthy-tissue is very plain. Sometimes spontaneous 
amputation may result from extensive gangrene. Other 
parts of the body may be affected, such as the cheeks, lips, 
deltoid muscles, and heels. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

It has to be differentiated from senile gangrene and 
from frost-bite. The age . of the patient will differentiate 
it in the first case, and the frequent recurrence of the local 
syncope will determine it in the second case. 



TTHAT IS THE PROGNOSIS ? 

There is a frequent recurrence of the disease after it has 
once existed in the patient, and the prospect of complete 
recovery is not very good. Sometimes the hand or foot 
may be amputated by the gangrenous process. 



WHAT IS THE TREATMENT? 

Remedial. — Arsenicum. — Gangrene of extremities; the 
affected part is hot and painful: stinging and tearing 
around the old scars. 

Carlo regetahilis. — Humid gangrene in cachectic persons 
whose vital powers are exhausted ; great prostration. 

Lachesis. — Coldness of the part as if ice were in contact 
with it, followed by tingling, heat and numbness; skin 
cracked and deep rliagades; bluish or black looking blisters. 

Secale. — Dry gangrene of the extremities; parts are dry, 
cold, hard, and insensible; the limbs become pale, cold, and 
shrivelled, losing all sensibility. 



ANGIONEUROTIC EDEHiA. 

WHAT IS ANGIONEUROTIC EDEMA ? 

A disease characterized by the rapid appearance of cir- 
cumscribed swellings on different parts of the body, but 
mainly upon the face. 



302 TROPHONEUROSES. 

WHAT ARE ITS CAUSES? 

It occurs oftener in men than in women, and is known 
to run in families, showing an hereditary tendency in some 
cases. It occurs oftener in winter and in the early morn- 
ing. Exhaustion, sudden exposure to cold, slight blows 
upon the part, great mental anxiety, grief, and the inges- 
tion of some kinds of food, such as apples, fish, or straw- 
berries may produce it. 



WHAT ARE THE SYMPTOMS ? 

The condition comes on suddenly, without premonitory 
symptoms. In a few minutes or hours there may be devel- 
oped a circumscribed edematous swelling upon the face, 
lips, tongue, hands, or genital organs. The parts feel stiff, 
with scalding, burning, and sometimes an itching sensa- 
tion. The affected part is usually pale, but may be slightly 
reddened. The swelling may cover a space an inch or two 
in diameter, though it may be four inches in diameter, and 
it may be multiple or several swellings may coalesce. They 
may last a few hours or a few days and then pass away, to 
return after a few weeks or three, or four months. When 
the disease attacks the throat dyspnea may be produced 
which is quite serious. 



WHAT IS THE DIFFEKENTIAI. DIAGNOSIS ? 

The symptoms of the disease are so peculiar that it is 
not easily mistaken for anything else. The sudden appear- 
ance of the edema at intervals, without evidences of inflam- 
mation is the pathognomonic condition for the diagnosis. 



WHAT IS THE PROGNOSIS ? 

The attacks may recur frequently and some cases do not 
seem to recover completely. 



TVHAT IS THE TREATMENT ? 

General.— Articles of food which are likely to produce 
the trouble should be avoided. 

Remedial. — Apis.— Stinging, burning, prickling, smart- 
ing or itching sensation of the skin, with edematous swell- 



TROPHONEUROSES. 303 

ing; edema of the lips and face; face stiff and sensitive on 
pressure; hands swollen, white and glossy. 

Arsenicum. — Face and lips swollen and edematous, with 
drawing and stinging here and there; face cold and pale; 
swelling and dryness of parts affected; burning, needle-like 
pains. 

Belladonna. — Swelling of face, with slight redness and 
heat; tissues appear thickened; swelling lasts a day or two 
and then passes away; recurs frequently; vomiting may 
sometimes accompany the attacks. 

Calcarea carbonica. — Circumscribed swelling in different 
parts of the body with itching; skin pale; bloated appear- 
ance of the skin; chronic form of edema; round swellings 
which appear in different places. 

Bhiis toxicodendron. — Smooth, shining swelling of the 
skin with itching; one side of the face swollen with hard- 
ness and thickness of the skin; edema after getting wet. 



ACROriEQALY— MARIE'S DISEASE. 

TI^HAT IS ACROMEGAI.Y ? 

It is a disease characterized by a progressive enlarge- 
ment of the extremities, thorax and bones of the face. 



WHAT ARE ITS CAUSES? 

It affects men about as frequently as women, and usually 
occurs between eighteen and thirty years of age. No special 
exciting causes are known. 



WHAT IS THE PATHOLOGICAL ANATOMY? 

Enlargement of the pituitary body has been found in 
some cases, which suggests that the disease may be due to 
some disorder of its function. As the function of this body 
is not well known nothing certain can be determined about 
it. Enlargement of the thymus gland has been found. 
Hypertrophy of the thyroid gland has been present in some 
cases while its atrophy has occurred in others. 



WHAT ARE THE SYMPTOMS ? 



There is a gradual enlargement of the hands, feet and 
head. In women there is suppression of the menses, and in 



304 TKOPHO-NEUROSES. 

men impotency. There is a general feeling of weakness and 
apathy, associated with frontal headache, dragging pains 
and anesthesia in the extremities. There is also increase of 
desire for food and drink, and increase in weight. The 
patient is not able to think as quickly as formerly. Exces- 
sive perspiration and increase of urine are noticed. The 
patient may stand severe cold without feeling it. When 
standing the neck is bent forward and the head is tilted 
backward. In order to bring his eyes upon a level the shoul- 
ders are bent forward. The gait is heavy and non-elastic. 
The nose, lips and tongue are sometimes enormously swollen, 
the ears become greatly increased in size, and the eye-lids 
grow thick. There is also enlargement of the superior 
maxillary bones, causing a lengthening of the face. The 
inferior maxillary bone increases in size in all directions. 
The cheeks are flattened and the zygoma stands out promi- 
nently. The eyes are dull and the patient has a sad expres- 
sion. The extremities are greatly enlarged and also the 
trunk. The wrists are enlarged and thickened, and the feet 
are flat and enlarged. Kyphosis is present, as is also scoliosis. 



WHAT IS THE DIFFERENTIAL DIAGNOSIS ? 

It has to be differentiated from myxedema. In the latter 
condition there is no enlargement of the bones, the face is 
round, skin pale, waxy and shiny, and the fingers clubbed 
at the ends. 

From elephantiasis it may be differentiated by its ab- 
sence of thickening and induration of the cutaneous tissue 
and of wasting of the muscles. 



WHAT IS THE PROGNOSIS ? 

Acromegaly is incurable, but it may be sometimes ar- 
rested by treating the disease symptomatically. 



WHAT IS THE TREATMENT ? 

GrENERAL.— The patient's strength should be kept up by 
good nutritious food, and he should exert himself as little 
as possible while in a weakened condition. 

Remedial.— The remedies will have to be prescribed for 
the general symptoms, such as frontal headache, general 



TROPHO-NEUKOSES. 305 

weakness, pains in the extremities and paresthesia, and for 
the mental condition. Belladonna^ Baryta carbonica^ Cat- 
carea carhonica^ Phosphorus^ Silica^ Selenium and Sulphur. 



ERYTHROriELALGIA. 

WHAT IS EKYTHROMEI.AI.GIA ? 

It is a disease mainly affecting the feet, and character- 
ized by burning pains and congestion of the parts, v:ith 
redness and swelling. 



WHAT ARE ITS CAUSES ? 

It occurs usually in men and during middle life. It 
may follow severe physical exertion while on the feet. It 
may also follow long-continued low fevers when the physi- 
cal condition is below par. 



WHAT IS THE PATHOEOGICAE ANATOMY ? 

There is sometimes a plantar neuritis, and occasionally 
disease of the spinal cord. 



WHAT ARE THE SYMPT03IS? 

There are congestion and swelling of the feet, with 
burning pain. Sometimes the parts become intensely red. 
Usually both feet are involved, though one alone may be 
affected. The flushing of the painful part is the most char- 
acteristic symptom. The veins stand out as if a cord were 
tied around the leg. There is profuse perspiration of the 
parts. In severe cases the limbs become cold and pale when 
the patient is at rest. The feet become so painful and 
tender that standing or walking is impossible. The hands 
may be effected in some cases. 



WHAT IS THE DIFFERENTIAE DIAGNOSIS ? 

The diagnosis must be made from pedalgia and alcoholic 
neuritis. 

In pedalgia there is no swelling or redness. In alcoholic 
neuritis there is no redness. 



306 TROPHO-NEUKOSES. 

WHAT IS THE TREATMENT ? 

General. — The patient should keep his feet elevated as 
much as possible, and perhaps remain in bed for a period of 
time. 

Remedial. — Belladonna. — Feet hot, swollen, burning, 
throbbing and painful; worse when putting the foot down; 
tension in soles of the feet; heaviness and tired feeling in 
the limbs. 

Causticum. — Feet hot, tense and swollen, with perspira- 
tion ; foot feels contracted, with tension on putting it to the 
ground; feet go to sleep. 

Nitric acid. — Swelling and pain in the feet with itching ; 
they inflame from the slightest degree of cold; great red- 
ness of the parts with intense heat; paralytic pain in the 
leg with excessive heaviness and lassitude. 



MORTON'S NEURALGIA— METATARSAL NEURALGFA. 

WHAT IS MORTON'S NEURAI.GIA ? 

It is a pain located at the back of the fourth toe, which 
usually extends up the leg. It is dull, throbbing, lancin- 
ating in character and usually comes on in spasms. The 
pain may be so severe at times that it prevents walking for 
a few minutes. It is increased by lateral pressure on the 
foot. It is supposed to be caused by squeezing the foot in 
too small a shoe, which produces a bruising of the nerve 
by the fifth bone. It is most common in women. Ordi- 
nary cases are relieved by changing the shoe so that it does 
not press upon the bone. 



TARSALGIA— POLICEMAN'S DISEASE. 

WHAT IS TARSAI.GIA ? 

It is a neuralgic affection generally due to flattening of 
the feet and stretching of the plantar ligaments ; or to a 
contusion of the covering of the os calcis. It occurs in 
persons who are on their feet a great deal when not being 
accustomed to it. Raw recruits suffer frequently from this 
condition when going on long marches. 

The treatment consists in resting and being off the feet 
as much as possible. 



INDEX. 



ABDUCENS NERVE 35 

Achromatopsia 53 

Acromegaly 67-303 

Acute atrophic paralysis 177 

ascending paralysis 181 

hydrocephalus 79 

suppurative encephalitis. 112 

transverse myelitis 170 

Afferent nerves 1 

Agraphia 56 

Alexia 57 

Amblyopia 53-137 

Amaurosis 54-137 

Amimia 57 

Amyotrophic lat. spin, scler. . .64 

Analgesia 48 

Analgic panaripium 210 

Anarthria 57 

Anemia of the brain 84 

remedies in 85 

Anesthesia 48-128-142 

thermo-anesthesia 48 

Anesthetic leprosy 250 

Angioneurosis 49 

Angioneurotic edema 67-301 

Angio-paralysis 49 

Angio spasm 49 

Ankle-clonus 70-73 

Anorexia 50 

Anosmia 55-121 

Anterior cornua 29 

Anterior crural nerve 239 

neuralgia of 239 

paralysis of 239 

Anthropathies 49 

Aphasia 56-98-106 

amnesic 56 

Aphemia 57 



Page 

Apoplexy 65-89 

Apraxia 57 

Arachnoid membrane 7-37 

Argyle-Robertson pupil 67 

Arthritic muscular atrophy. .216 

Associating fibres 25 

Asthenopia 53 

Asymbolia 57 

Ataxia, cerebellar 49 

hereditary 197 

locomotor 63-185 

motor 48 

static 48 

Ataxic paraplegia 195 

Athetosis 48-106 

Attitudes in diseases 63 

Atrophy 49 

arthritic muscular 216 

idiopathic muscular 220 

of brain 133 

of optic nerve ., 136 

progressive muscular 63 

progressive spinal muse . . 199 

Auditory dysesthesia . . 55 

hyperesthesia 152 

nerve 35-150 

Aurje 260 

Aural vertigo 55 

Automatic action of spin. cord. 42 

BASAL GANGLIA 19 

Basedow's disease 292 

Beri-beri 247 

Blood supply of spinal cord. . .42 

Brachial plexus 44-232 

paralysis 232 

spasm 234 

neuritis ...... ^ 234 



11 



INDEX. 



Page 

Brain, anemia uf 84 

atrophy of 133 

cystic degeneration of . . . 125 

definition of 4 

diseases of 75 

hyperemia of 86 

hypertrophy of 134 

membranes of 5 

softening of 126 

ventricles of 29 

weight 4 

Bulbar paralysis 130 

Bulbs, olfactory 18 

Bulimia 50 

CAISSON DISEASE 184 

Calcarine fissure 10 

Calloso-marginal fissure 10 

Caudate nucleus 20 

Cardiac nerves 155 

Catalepsy 257 

Cells of Purkinje 27 

Centrum ovale 25 

Cerebellar ataxia 49 

disease 64 

Cerebellum 26 

divisions of 26 ' 

function of 27 

Cerebral acute palsy 105 

arteries 32 

birth-palsy 95 

centres 31 

embolism 93-98 

hemorrhage 89-99 

localization 31 

softening 101 

thrombosis 99 

tumors 93 

Cerebro-spinal system 1 

nerves 1 

Cerebrum, convex surface of . . .9 

convolutions of 11 

cortex of 14 

Cervical plexus 229 

Cervico-occipital neuralgia . . . 229 

Chorea... 264 

common 264 

electrical 266 

habit 266 

hereditary, Huntington's . 266 

saltatoric spasm 266 

Sydenham's 264 



rage 

Choreic movements 48 

Choroid plexus 30 

Chronic progressive softening 

of the brain 126 

hydrocephalus 80 

myelitis 175 

Circle of Willis 32 

Columns of Turck 38 

of Goll 38 

of Burdach 38 

visceral, of Clarke 39 

Coma 93 

Commissural fibres 25 

Constipation 51 

Contractures 18-120 

Convulsions 

48-77-91-99-106-114- L21 

Convulsive tic 48 

Cornua, anterior 29 

posterior 29 

Corona radiata 23-25 

Corpora albicantia 19 

quadrigemina 23 

Corpus callosum 17 

striatum 19 

• fimbriatum 30 

Corpuscles, Pacinian 3 

tactile, of Wagner. 3 

Cortical layers 14 

Cramp 297 

telegraphers' 297 

goldbeaters' 297 

piano-players' 297 

Cranial nerves 1-32-135 

deformities 106 

Cystic degeneration of the 
brain 125 

DEFECTIVE GROWTH .... 106 

Deformities, paralytic 179 

mental 106 

Delayed sensation 49 

Delirium 77 

Digestive tract symptoms 50 

Digiti-mortui 67 

Diplegia 47 

Diplopia 53 

Diphtheritic paralysis 294 

Disseminated sclerosis 127 

Divers' paralysis 184 

Dizziness 120 

Dorsal nerves 236 



INDEX. 



Ill 



rage 

Dual consciousness 261 

Dura mater, processes of . . . 5-37 

Dyspnea 163 

Dystrophy 49 

EAR SYMPTOMS 54 

Edema, angioneurotic 301 

Efferent nerves. 1 

Electrical irritability 50-202 

chorea 266 

reactions 179 

Electro-diagnosis 72 

Encephalitis 109 

remedies in 111-115 

acute suppurative 112 

Encephalomalacia 101 

treatment in 102 

End-bulbs of Krause 3 

End-organs, peripheral 3 

Ependyma 29 

Epidemic cerebro spinal men- 
ingitis 78 

Epileptiform neuralgia 144 

Epilepsy 259 

cry of 260 

hystero-epilepsy 261 

dual consciousness of . . . .261 

Erythromelalgia 305 

Esophageal nerves 156 

Exaggerated reflexes 106-128 

Examination for reflexes 70 

Exophthalmic goitre. ....... .292 

External popliteal nerve, par- 
alysis of 240 

Eye symptoms 52-128 

FACE 92 

Facial nerves 35-146 

neuralgia 143 

spasm , . « . 146 

paralysis 148 

Falx cerebelli 5 

cerebri 5 

" Fasting girls " 255 

Fever 178 

Fibres, associating 25 

commissural 25 

fornix 25 

nerve 2 

Fibrillary tremor 48 

Friedreich's disease 197 



J 'age 

symptoms of 198 

Fifth nerve, paralysis of 141 

Fissure, calcarine 10 

calloso-marginal 10 

hippocampal 10 

of Rolando 10 

of Sylvius 9 

Fornix fibres 25 

Fothergill's neuralgia 144 

Frontal lobe 11 

Functional nerve dis. symp .... 47 

GAIT IN DISEASES 63 

Gastric nerves 156 

Gland, pineal 25 

Globus hystericus 254 

Glosso-pharyngeal nerve . .35-153 

Goitre, exophthalmic 292 

Goldbeaters' cramp 297 

Grand mal 261 

Grave's disease 292 

Gustatory symptoms 56 

HABIT CHOREA 266 

Handwriting 128 

Headache 282 

in encephalitis 114 

in meningitis 163 

sick 285 

Hemianopsia 52-138 

Hemicrania 285 

Hemiparaplegia 47 

Hemiplegia 47-64 

Hereditary ataxia 197 

Herpes zoster 237 

Hippocampal fissure 10 

Hippoglossal nerve 36-159 

Huntington's chorea (heredi- 
tary) 266 

Hydromyelocele 213 

Hydrocephalus 79 

acute 79 

chronic 80 

Hydrophobia 276 

Hyperalgesia 49 

Hyperemia of the brain ... 86 

Hyperesthesia 49-55 

Hypergeusia 56 

Hyperosmia 56 

Hypertrophy 49 

of brain 134 



IV 



INDEX. 



Page 

Hysteria 253 

mental symptoms of 254 

Hystero-epilepsy 261 

IDIOPATHIC MUSCULAR 

ATROPHY 223 

Impotence 52 

Inability to void urine 51 

Incontinence of feces 51 

of urine 51 

Inco-ordination of muscles. . 48-97 

of lower extremities 186 

Inflammation of optic nerve.. 136 
Infantile meningeal h e m o r - 
rhage 95 

hemiplegia 105 

spinal paralysis 177 

Inspection 57 

Insular sclerosis 127 

Intercostal nerves 44 

neuralgia 236 

Internal capsule 22 

Internal popliteal nerve, par- 
alysis of 241 

Interstitial neuritis 225 

Intra-cranial aneurism 124 

tumors 116 

Intra-ventricuiar portion 20 

Irritability, electrical 50-202 

myotatic 220 

Irritation of ocular nerve 140 

Island of Reil 13 

JAW 61 

•' Jumping sickness " 266 

KAKKE 247 

LAMINA CINEREA . : 17 

Laryngeal nerves 154 

paralysis 155 

spasm 155 

Lenticular nucleus 20 

Leprosy 249 

anesthetic 250 

Leprous neuritis 67-225-249 

symptoms of 186 

remedies in , 190 

Leptomeningitis 76 

acute simple 76 

Lethargy 257 

Ligamenta denticulatae 37 



Page 

Lobe, limbic 13 

occipital 13 

temporo-sphenoidal 13 

Lobule, cuneus 14 

of the cerebrum 13 

paracentral 13 

Lobulus quadratus : . .14 

Lock-jaw 273 

Locomotor ataxia 63-185 

Lordosis, in spinal atrophy . . . 202 
in pseudo-hypertrophic 

paralysis 219 

Loss of consciousness 91-99 

Lumbar plexus 44-45-238 

MARIE'S DISEASE 303 

Mastodynia .237 

Medullary sheath 2 

Medulla oblongata 27 

Meniere's disease 55 

Meningeal hemorrhage 95 

Meningitis, cerebro-spinal 78 

leptomeningitis 76 

pachymeningitis 75 

treatment of 82 

tubercular 79 

Meningocele , 212 

Meningomyelocele 213 

Mental defects 97-106 

symptoms 114-120-128 

Metatarsal neuralgia 306 

Microcephaly 133 

Migraine 285 

Minute anatomy of spin. cord. 40 

Monoplegia 47 

Morton's neuralgia 306 

Morvan's disease 210 

Motorial end plates 3 

Motor aphasia 56 

ataxia 48 

nerves 1 

nerves of eye 138 

oculi nerves 33 

symptoms 47 

Mouth, expressions of 61 

Multiple neuritis 224-244 

sclerosis 127 

Muscles, ocular 139 

Muscular atrophy, arthritic. .216 
progressive 63 



INDEX. 



Page 

progressive spinal 199 

simple idiopathic 220 

Myelin 2- 

Myelitis 170 

acute transverse 170 

chronic 175 

remedies in 174 

Myelocele 213 

Myotonia congenita 222 

strychnia in 223 

Myotatic irritability 270 

NASAL SYMPTOMS 55 

Nerves, abducens 35 

afferent 1 

anterior crural 239 

auditory 150 

cardiac 155 

deafness 150 

division of 3 

dorsal 236 

efferent 1 

esophageal 156 

external popliteal 240 

facial 34-146 

fibre 2 

gastric 156 

glosso-pharyngeal 35-153 

hypoglossal 36-159 

intercostal 54 

laryngeal 154 

obturator 239 

ocular 140 

olfactory 33 

patheticus 34 

peroneal 240 

pharyngeal 154 

phrenic 230 

pneumogastric 154 

pulmonary 155 

sciatic 240 

sensory 1 

structure of 2 

termination of 8 

Neuralgia 286 

cervico-occipital 229 

epileptiform 144 

facial 143 

Fothergill's 144 

intercostal 236 

mammary 237 



Page 

metatarsal 306 

Morton's 306 

of anterior crural nerve. .239 

remedies in 145-288 

Neurasthenia 278 

psychic disturbances in. .280 

Neurilemma 2 

Neuritis 22i 

interstitial 224 

leprous 225 

multiple 224-244 

optic 120-136 

parenchymatous 224 

simple 224 

syphilitic 67 

Neuromata 228 

Neurotic edema 301 

Neuroses, occupation 297 

Nodes of Ranvier 2 

Nucleus emboliformis 27 

f astigii 27 

globosus 27 

Nymphomania 52 

OBJECTIVE DISEASE 

SYMPTOMS 47 

Obturator nerve, paralysis of .2.39 

Occipital lobe 13 

Occupation neuroses 297 

Ocular muscles, insufficien- 
cies of J39 

nerves, irritation of 140 

Olfactory Ibulbs 18 

nerves 33 

tracts 18 

Ophthalmoplegia 138 

Opisthotonos 273 

Optic commissure 18 

nerve 33-136 

neuritis 120-136 

thalamus 19 

Organic nervous diseases 47 

Overflow-incontinence 51 

PACHYMENINGITIS, 

external 75 

internal 75 

Pacinian corpuscles 3 

Palsy, shaking 268 

Para-central lobule 13 

Parageusia 56 



VI 



INDEX. 



Page 
Paralysis, acute ascending , . .181 

acute atrophic 177 

agitans 63 

bulbar 130 

diphtheritic 294 

divers' 184 

infantile spinal 177 

musculo-spiral 64 

of anterior crural nerve . . 239 
of external popliteal, or 

peroneal nerve 240 

of fifth nerve 141 

of internal popliteal 241 

of myelitis 171 

of obturator nerve 239 

of pharynx 154 

of sciatic nerve 240 

of ulnar nerve 64 

progressive bulbar 130 

pseudo-hypertrophic 63 

Paralytic deformities 179 

Paraphasia 57 

Paraplegia 47-64 

ataxic 195 

primary spastic 61-191 

Parenchymatous neuritis 224 

Paresis 47-128 

Paresthesia 49-142 

Parietal fissure 11 

lobe 12 

Parieto-occipital fissure 10 

Patheticus nerve . H4 

Patillitis 136 

Peripheral end-organs 3 

Perineuritis 224 

Peroneal nerve, paralysis of. .240 

Petit mal 261 

Phantom tumors 255 

Pharyngeal nerves 154 

Phrenic nerve 230 

paralysis of 230 

spasm of 231 

Pia mater 8-37 

Piano-players' cramp 297 

Pineal gland 25 

Petuitary body 19 

Plexus, brachial. 232 

cervical 229 

lumbar 238 

sacral 240 



Page 

Policeman's disease 306 

Pneumogastric nerve 35 

Polio-myelitis-anterior 177 

Pons varolii 29 

Posterior cornua 29 

Posterior perforated space 19 

Primary lateral sclerosis 191 

spastic paraplegia 64-191 

Progressive spinal atrophy . . . 199 

softening of brain 126 

Prosopalgia 144 

Pulmonary nerves 155 

Pupillary reflexes 54 

Pupils 60 

Pulse, variations of 66 

Purkinje, cells of 27 

REACTION OF DEGENER- 
ATION 73 

electrical 179 

Rabies 276 

Raynaud's disease 300 

Reflex action 49 

Reflexes, exaggerated .... 106-128 

pupillary 54 

Respiration 77-91 

anomalies of 66 

Rigidity of muscles 48-106 

SACRAL PLEXUS 240 

Saltatoric spasm 266 

Satyriasis 52 

Sciatica 241 

Sciatic nerve, paralysis of 240 

Sclerosis — 

disseminated 127 

insular 127 

multiple 127 

primary lateral 191 

Sensory nerves 1 

symptoms 48-92-121 

Sexual symptoms 52 

Septum lucidum 29 

Shaking palsy 268 

Sheath of Schwann 2 

Shingles ■• 237 

Simple idiopathic muscular 

atrophy 220 

Simple neuritis 224 

Static ataxia 48 

Somnambulism • 257 



INDEX. 



Page 

Spasms 48-96 

facial 146 

of fifth nerve 142 

of pharynx 154 

saltatoric 266 

Special tests 67 

Speech symptoms 56-120-128 

Sphincters 172 

Spina bifida 212 

hydromyelocele 213 

meningocele 212 

meningomyelocele 213 

myelocele 213 

surgical treatment of .... 214 

syringomyelocele 213 

Spinal accessory nerve 36 

atrophy 199 

cord 36-204 

hemorrhage 167 

meningitis 160 

nerves 1-43 

Spotted fever 78 

St. Vitus' dance 264 

Strabismus 121 

Stupor 77 

Sub-arachnoid spaces 7 

Subjective disease symptoms.. 47 

Sydenham's chorea 264 

Sympathetic nervous system ... 2 

Syphilitic neuritis 67 

Syringomyelia 208 

TABES DORSALIS 185 

Tactile corpuscles of Wagner... 3 

Tarsalgia 306 

Telegraphers' cramp 297 

Temperaments 58 

Temperature 77-92-99-114 

Temporo-sphenoidal lobe 13 

Tenia hippocampi 30 

Tentorium cerebelli 6 

Tests for accomodation 68 

for disordered motility 68 

for disordered sensation ... 71 

for hearing 68 

special 67 



Vll 

Page 

Tetanus 272 

Tetany 275 

Thomsen's disease 222 

Thrombosis 

cerebral 99 

in cerebral sinuses and 

veins 103 

Tic douloureux 144 

Tinnitus aurium 55-152 

Torticollis 290 

Tracts, olfactory 18 

Trance 257 

Transverse fissure 11 

Tremor 47-128 

fibrillary 48 

Trifacial nerve 34 

Trigeminus i41 

Trismus 273 

Trophic disturbances .. .47-92-142 

Tropho-neuroses 300 

Tuber cinereum 18 

annulare 29 

Tubercular meningitis 79 

Tumors — 

intracranial 116 

of spinal cord 204 

phantom 255 

remedial treatment of . . .207 

ULNAR NERVE, PAR- 
ALYSIS OP 64 

Uremia 93 

Urinary symptoms 51 

VALLECULA 18 

Vaso-constrictors 2 

dilators 2 

Vasomotor centres 2 

disturbances 67 

Ventricles of the brain 29 

Vertigo 289 

aural 55 

Visceral columns of Clarke 39 

Vomiting 50-99-114-120 

WRITER'S CRAMP. 297 

Wry-neck 290 



